north carolina medical journal jan-feb 2009

Published by the North Carolina Institute of Medicine and The Duke Endowment

The Face ofAddictionand the

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Also inthis

Issue:

HealthReform in

North Carolina

www.ncmedicaljournal.com

January/February2009,70:1

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The North Carolina Institute of MedicineIn 1983 the North Carolina General Assembly chartered the North Carolina Institute of Medicine as an independent,quasi-state agency to serve as a nonpolitical source of analysis and advice on issues of relevance to the health of NorthCarolina’s population. The Institute is a convenor of persons and organizations with health-relevant expertise, aprovider of carefully conducted studies of complex and often controversial health and health care issues, and a sourceof advice regarding available options for problem solution. The principal mode of addressing such issues is through theconvening of task forces consisting of some of the state’s leading professionals, policymakers, and interest grouprepresentatives to undertake detailed analyses of the various dimensions of such issues and to identify a range ofpossible options for addressing them.

The Duke EndowmentThe Duke Endowment, headquartered in Charlotte, NC, is one of the nation’s largest private foundations.Established in 1924 by industrialist James B. Duke, its mission is to serve the people of North Carolina and SouthCarolina by supporting programs of higher education, health care, children’s welfare and spiritual life. TheEndowment’s health care grants provide assistance to not-for-profit hospitals and other related health careorganizations in the Carolinas. Major focus areas include improving access to health care for all individuals,improving the quality and safety of the delivery of health care, and expanding preventative and early interventionprograms. Since its inception, the Endowment has awarded $2.2billion to organizations in North Carolina and South Carolina,including more than $750million in the area of health care.

Publishers of the North Carolina Medical Journal

CALL FORSUBMISSIONS

The run up to the November election brought a lot of attention to health reform. Bothmajor candidatespresented relatively complete plans for major changes in the way we pay for health care and how westructure our health care delivery system. The appointments by President Obama point to a sustainedeffort to implement real change. This has prompted many experts and representatives of patients,providers, and payers to propose their own plans for reform. The North Carolina Medical Journalwill betaking a part in this discussion with a section of the Journal devoted to articles and analyses that focuson reform. We would like to invite submissions that help the readership of the Journal understand whyreformmay be necessary, how the system should be changed, and hownational reformwill affect NorthCarolina. We invite scholarly discussions and analyses as well as commentaries that help illustrate thebenefits aswell as the problems that comprehensive changewill bring to the costs, quality, andoutcomesof health care and to the health of the people of North Carolina. The first installment of this new seriesstarts on page 20 of this issue of the Journal.

2 NCMed J January/February 2009, Volume 70, Number 1

Publisher Pam C. Silberman, JD, DrPH / NC Institute of Medicine, MorrisvillePublisher Eugene W. Cochrane Jr / The Duke Endowment, CharlotteEditor-In-Chief Thomas C. Ricketts III, PhD, MPH / University of North Carolina, Chapel HillScientific Editor John W. Williams Jr, MD, MHS / Duke University Medical Center, DurhamAssistant Scientific Editor Ben Powers, MD, MHS / Duke University Medical Center, DurhamEditor Emeritus Gordon H. DeFriese, PhD / University of North Carolina, Chapel HillEditor Emeritus Francis A. Neelon, MD / Duke University, DurhamAssociate Editor Dana D. Copeland, MD, PhD / WakeMed, RaleighAssociate EditorMark Holmes, PhD / NC Institute of Medicine, MorrisvilleAssociate EditorMary L. Piepenbring / The Duke Endowment, CharlotteAssociate Editor Charles F. Willson, MD / East Carolina University, GreenvilleSection Editor, Running the Numbers Paul A. Buescher, PhD / NC DHHS, RaleighManaging Editor Christine Nielsen, MPH / NC Institute of Medicine, MorrisvilleAssistant Managing Editor Phyllis Blackwell / NC Institute of Medicine, MorrisvilleBusiness Manager Adrienne R. Parker / NC Institute of Medicine, Morrisville

Editorial BoardCynthia B. Archie, RN, EdD / Wayne Community College, GoldsboroWilliam K. Atkinson II, PhD, MPH / WakeMed, RaleighJ. Steven Cline, DDS, MPH / Division of Public Health / NC DHHS, RaleighFred M. Eckel, MS / NC Association of Pharmacists, Chapel HillElizabeth R. Gamble, MSPH, MD /Wake Forest University, Winston-SalemTed W. Goins Jr / Lutheran Services for the Aging, Inc, SalisburyBeth A. Griffin, MHP, PA-C / New Hanover Community Health Center, WilmingtonBlaine Paxton Hall, PA-C / Durham Regional Hospital, DurhamMargaret N. Harker, MD / Family Practice, Morehead CityRobert T. Harris, MD / Trust for America’s Health, RaleighOlson Huff, MD / Action for Children North Carolina, AshevilleThomas G. Irons, MD / East Carolina University, GreenvilleDelma H. Kinlaw, DDS / NC Dental Society, CaryJulienne K. Kirk, PharmD /Wake Forest University, Winston-SalemRicky L. Langley, MD, MPH / Division of Public Health / NC DHHS, RaleighMark Massing, MD, PhD / The Carolinas Center for Medical Excellence, CaryJane B. Neese, RN, PhD / University of North Carolina, CharlotteM. Alec Parker, DMD / NC Dental Society, FletcherDeborah Porterfield, MD, MPH / Division of Public Health / NC DHHS, RaleighSenator William R. Purcell, MD / NC General Assembly, LaurinburgDennis R. Sherrod, RN, EdD / Winston-Salem State University, Winston-SalemPolly Godwin Welsh, RN-C / NC Health Care Facilities Association, RaleighJoyce M. Young, MD, MPH / IBM Corporation, Research Triangle Park

TheNorth CarolinaMedical Journal (ISSN 0029-2559) is published by the North Carolina Institute ofMedicineand The Duke Endowment under the direction of the Editorial Board. Copyright 2008 © North CarolinaInstitute of Medicine. Address manuscripts and communications regarding editorial matters to the managingeditor. Address communications regarding advertising and reader services to the assistant managing editor.Opinions expressed in the North Carolina Medical Journal represent only the opinions of the authors and donot necessarily reflect the official policy of the North Carolina Medical Journal or the North Carolina Instituteof Medicine. All advertisements are accepted subject to the approval of the editorial board. The appearanceof an advertisement in the North Carolina Medical Journal does not constitute any endorsement of the subjector claims of the advertisement. This publication is listed in PubMed.Managing Editor:ChristineNielsen,MPH, 919.401.6599, ext. 25 or christine_nielsen (at) nciom.org.AssistantManagingEditor:PhyllisA. Blackwell, 919.401.6599, ext. 27or phyllis_blackwell (at) nciom.org.GraphicDesign:Angie Dickinson, angiedesign (at) windstream.net. Printing: The Ovid Bell Press, Inc, 1201-05 Bluff Street,Fulton, MO 65251, 800.835.8919.Annual Subscriptions (6 issues): Individual $42.80 ($40 plus 7%NC tax).Institutional: $64.20 ($60 plus 7%NC tax).The North Carolina Medical Journal (ISSN 0029-2559) is published bimonthly: January/February, March/April,May/June, July/August, September/October, andNovember/December. Periodicals postagepaid atMorrisville,NC27560andat additionalmailing offices.POSTMASTER:Sendaddress changes to theNorthCarolinaMedicalJournal, 630DavisDrive, Suite 100,Morrisville, NC27650.CanadaAgreementNumber: PM40063731. ReturnundeliverableCanadianaddresses to: StationA,POBox54,Windsor,ONN9A6J5, Email: returnsil (at) imex.pb.com

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Founded by the North Carolina Medical Society in 1849Published by the North Carolina Institute of Medicine and The Duke Endowment

Cosponsors of the North Carolina Medical Journal are The Carolinas Center for Medical ExcellenceNorth Carolina Association of Pharmacists / North Carolina Dental Society / North Carolina HealthCare Facilities Association / North Carolina Hospital Association / North Carolina Medical SocietyMembers of these organizations receive the Journal as part of their membership fees. Additional majorfunding support comes from The Duke Endowment.

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North Carolina MedicalJournal reaches morethan 36,000 health careprofessionals and policyshapers directly, and eachmonth more than 50,000access the Journal via ourwebsite—making it themost widely distributedNorth Carolina-based,health-focused journal

in the state.

3NCMed J January/February 2009, Volume 70, Number 1

Tarheel Footprints in Health CareRecognizing unusual and often unsung contributions of individual citizens who have made

health care for North Carolinians more accessible and of higher quality

Flo Stein, MPH

Don’t let her small stature and soft-spoken nature fool you. Flo Stein leaves a large footprintwherever she goes as an innovator, leader, and advocate for people with substance abuseproblems, as well as those with mental health concerns and developmental disabilities. Aschief of Community Policy Management in the North Carolina Division of Mental Health,DevelopmentalDisabilities, andSubstanceAbuseServices (DMHDDSAS), Flo’s responsibilitiesextend to all aspects of community services planning, development, and evaluation withinthe state’s Local Management Entities (LMEs) and in the local provider system.

A proudWashington state native from a military family, Ms. Stein moved toWilmington, North Carolina, andbegan her career here in 1971 as a substance abuse prevention specialist with the New Hanover County DrugAbuse Committee. She graduated with a BA degree in social sciences from the University of North Carolinaat Wilmington and subsequently completed her master’s of public health (MPH) degree in Health Policy andAdministration from the University of North Carolina at Chapel Hill (UNC). Flo is a passionate UNC supporterand “bleeds blue” like most true Tarheels.

While completing her education, Flo founded and was the first director of Open House, Inc., a 24-hour crisiscenter providing counseling, shelter, and free medical care in New Hanover County. Flo subsequently servedas the clinical director, deputy director, and executive director of Cape Fear Substance Abuse Center, Inc., anot-for-profit comprehensive drug prevention and treatment program where she developed the TreatmentAccountability for Safer Communities (TASC) program and established a nationally recognized prison treatmentprogram.

Moving her efforts to the state level in 1987, Ms. Stein began her work in DMHDDSAS’s “Challenge 87”Substance Abuse Community Coalition Initiative and the early development of statewide adolescent substanceabuse services. This work was closely coordinated with the work of Dr. Jonnie H. McLeod, chair of theGovernor’s Council on Alcohol and Drug Abuse and the Governor’s Interagency Advisory Council on Alcoholand Drug Abuse among Children and Youth. Since then, Flo has taken on an ever-increasing amount ofresponsibility within DMHDDSAS from assistant chief to chief of the Substance Abuse Services Section to hercurrent position as chief of the Community Policy Management Section. In this capacity, Flo is responsible foroverseeing all aspects of community care for individuals and their families affected by substance abuse, mentalillness, and developmental disabilities.

Flo has served on numerous statewide and national commissions, task forces, expert panels, and advisorygroups, and has impacted services for persons with substance abuse and other disabilities, including fundingand policy development, community corrections, AIDS services, welfare reform, women’s services, andnational outcomes measures. Within the state, Ms. Stein has been recognized for her leadership and serviceas a recipient of the Norbert L. Kelly Award, presented by the Addiction Professionals of North Carolina, aswell as awards from the North Carolina Substance Abuse Professional Practice Board, the North CarolinaAssociation of Behavioral Health Care, and the North Carolina Association of Drug Abuse Directors.

On the national level, Flo has provided outstanding leadership and advocacy for substance abuse, mentalhealth, and developmental disabilities for many years. In November 2008, she was appointed by theSubstance Abuse and Mental Health Services Administration (SAMHSA) to its National Advisory Council.The SAMHSA National Advisory Council is a 12-member panel of experts who advise the US Department ofHealth and Human Services Secretary and SAMHSA’s administrator on a wide range of public health mattersrelated to prevention, treatment, and recovery support services.


continued on page 6

January/February 2009,Volume 70, Number 1 Published by theNorth Carolina Institute ofMedicine and TheDuke Endowment

PEER-REVIEWEDARTICLES9 Perceptions vs. Reality: Measuring of Pleural

Fluid pH in North CarolinaMark R. Bowling, MD; Arjun Chatterjee, MD, MS;John Conforti, DO; Norman Adair, MD;Edward Haponik, MD; Robert Chin Jr, MD

14 Postpartum Glucose Tolerance Screening inWomen with Gestational Diabetes in the Stateof North CarolinaArthur M. Baker, MD; Seth C. Brody, MD, MPH;Kathryn Salisbury; Robin Schectman;Katherine E. Hartmann, MD, PhD

POLICY FORUMSubstance Abuse in North Carolina24 Introduction

Thomas C. Ricketts III, PhD, MPH; Christine Nielsen, MPH

25 Issue Brief: Substance Abuse in North CarolinaPam C. Silberman, JD, DrPH; Representative Verla Insko;Senator Martin L. Nesbitt Jr, JD; Dewayne Book, MD;Kimberly Alexander-Bratcher, MPH; Berkeley Yorkery, MPP;Jennifer Hastings, MS, MPH; Daniel Shive, MSPH;Jesse Lichstein, MSPH; Mark Holmes, PhD

COMMENTARIES35 Drug Addiction:

A Chronically Relapsing Brain DiseaseDavid P. Friedman, PhD

38 Substance Abuse Screening and BriefIntervention in Primary CareSara McEwen, MD, MPH

43 Recovery-Oriented Systems of Care, the Cultureof Recovery, and Recovery Support ServicesDonna M. Cotter, MBA

46 Making the Public Mental Health,Developmental Disabilities, and SubstanceAbuse SystemMore Accessible:An Invitation to RecoveryFlo Stein, MPH

50 The Emerging Role of Prevention and CommunityCoalitions: Working for the Greater GoodPhillip W. Graham, DrPH, MPH;Phillip A. Mooring, MS, CSAPC, LCAS

54 Substance Use Treatment Needs AmongRecent VeteransA. Meade Eggleston, PhD;Kristy Straits-Tröster, PhD, ABPP; Harold Kudler, MD

59 Physician Health vs. Impairment:The North Carolina Physicians Health ProgramWarren Pendergast, MD; Jim Scarborough, MDiv

62 Substance Abuse Treatment Continuum in theNorth Carolina Department of CorrectionVirginia Price

66 Drug Treatment CourtsKirstin Frescoln

70 Substance Abuse Services and Issues inCommunity Offender SupervisionRobert Lee Guy; Timothy Moose; Catherine Smith

72 The Physician’s Role in Treating Addiction as aDiagnosable and Treatable IllnessDewayne Book, MD

75 Adequacy of the Substance AbuseWorkforceAnna Misenheimer

78 Oxford Houses and My Road to RecoveryKathleen Gibson

DEPARTMENTS4 Tarheel Footprints in Health Care

80 Philanthropy Profile

82 Running the Numbers

85 Spotlight on the Safety Net

87 Classified Ads

88 Index of Advertisers

5NCMed J January/February, Volume 70, Number 1

Also in this issue:20 Health Reform in North Carolina: Lessons

from the Past and Prospects for the FutureThomas C. Ricketts III, PhD, MPH


continued from page 4

Throughout her career, Flo has prominently supported services to persons in the criminal justice system. Shewas awarded the 2003 State Leadership Award from National Treatment Alternatives for Safer Communities“for her exceptional leadership, unprecedented partnership, devoted service, and outstanding contributionsto improve the lives of substance abusing individuals in the criminal justice system.” Flo has been recognizedrepeatedly for her many years of service to the National Association of State Alcohol and Drug AbuseDirectors (NASADAD) and currently serves as its president. NASADAD is the substance abuse single stateauthority membership organization that works to foster and support the development of effective alcohol andother drug abuse prevention and treatment programs across the nation. NASADAD also serves as the focalpoint of the states and territories in the examination of alcohol and other drug-related issues with federalagencies and other national organizations.

Two outstanding North Carolina womenwho have inspired Flo are Johnnie HornMcLeod,MD, of Charlotte, andNancy Bryan “Lady” Faircloth. Dr. McLeod is a tireless advocate for drug treatment services in this state andrecipient of the US National Library of Medicine “Local Legends Award: Celebrating America’s Local WomenPhysicians.” “Lady” Faircloth, a 1982 “Tarheel of the Week,” mentored Flo in her early years within the NorthCarolina Department of Human Resources.

Flo is married to L.Worth Bolton, a fellowUNC graduate employed by the UNC School of SocialWork and himselfa longtime advocate and professional counselor for peoplewith substance abuse problems and other disabilities.Flo is also the proud mother of one daughter, Kim Stein-Hoppin, a practicing attorney, and a granddaughterEmma, the charm of Flo’s life. Flo loves to garden and is a long-time member of the Friends of the JC RaulstonArboretum at North Carolina State University. She celebrates her Danish heritage through involvement withRaleigh’s Friends of Scandinavia, loves antiquing, and when traveling, loves to have the opportunity to visit localmuseums.

North Carolina is privileged to be the home of such a tireless and influential advocate for the citizens of ourstate and of our nation.

Contributed bySpencer Clark, assistant section chief, and Joan Kaye, projects manager, of the Community Policy Management Section

of the North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services.

www.carolinasmedicalcenter.org

No matter where you live, work or playin our region, chances are there’s a Carolinas Medical Center facility or

physician near you. Giving you access to more specialists, greater depths of

expertise and our uncompromising excellence and commitment to care. It’s who

we are at Carolinas Medical Center. And where we are, is near you. Visit our

website for more information on our outstanding physicians.


Perceptions vs. Reality:Measuring of Pleural Fluid pH in North Carolina

Mark R. Bowling, MD; Arjun Chatterjee, MD, MS; John Conforti, DO; Norman Adair, MD;Edward Haponik, MD; Robert Chin Jr, MD

PEER-REVIEWED ARTICLE

Abstract

Background: Pleural fluid pH anaerobically handled and measured by a blood gas analyzer (BGA) is used to define a pleural spaceinfection as complicated and predict the life expectancy of patients with malignant pleural effusions. Pleural fluid pH can also be measuredby other less accurate methods. It is unknown whether physicians who use pleural fluid pH measurements are aware of the method usedby their laboratories.Methods:We surveyed 90 pulmonary physicians in North Carolina about their use of pleural fluid pH and their hospital laboratory’s

approach (pH indicator stick, pH meter, or BGA). We then contacted their hospital laboratories to determine the actual method of pHmeasurement.Results: Twenty-eight (31%) pulmonologists in 11 North Carolina hospitals responded on their use of pleural fluid pH. Of the 20

pulmonologists who order pleural fluid pH, 90% reported that their hospital measures pleural fluid pH via BGA, but the majority (72%)were inaccurate. Only two of 11 hospitals reported that they measure pleural fluid pH with a BGA.Conclusion: Almost two-thirds of the chest physicians that order pleural fluid pH to help manage pleural effusions were using

information that is not substantiated by the literature and, despite previous reports, hospitals still use suboptimal methods to measurepleural fluid pH. Further information is needed concerning the barriers to physicians and laboratory practices concerning the use of BGAfor the measurement of pleural fluid pH.Keywords: pleural effusion; pleural fluid pH; complicated parapneumonic effusion; malignant pleural effusion

Mark R. Bowling MD, is an assistant professor of medicine and director of interventional pulmonology in the Division of Pulmonary, CriticalCare, and SleepMedicine at the University ofMississippi School ofMedicine. He can be reached at mbowling (at) medicine.umsmed.edu.

Arjun Chatterjee, MD, MS, is an assistant professor in the Pulmonary, Critical Care, Allergy, and Immunologic Diseases section of theWake Forest University School of Medicine and Baptist Medical Center.

John Conforti, DO, is an associate professor in the Pulmonary, Critical Care, Allergy, and Immunologic Diseases section of the WakeForest University School of Medicine and Baptist Medical Center.

Norman Adair, MD, is an associate professor in the Pulmonary, Critical Care, Allergy, and Immunologic Diseases section of the WakeForest University School of Medicine and Baptist Medical Center.

Edward Haponik, MD, is a professor in the Pulmonary, Critical Care, Allergy, and Immunologic Diseases section of the Wake ForestUniversity School of Medicine and Baptist Medical Center.

Robert Chin Jr, MD, is an associate professor in the Pulmonary, Critical Care, Allergy, and Immunologic Diseases section of the WakeForest University School of Medicine and Baptist Medical Center.

t is estimated that there are fourmillion cases of community-acquired pneumonia in the United States annually with

one-quarter requiring hospitalization.1 Parapneumonic effusionscomplicate the course of 57% of patients with bacterialpneumonia.2-4 Coupled with other clinical information, themeasurement of the pleural fluid pH is important in themanagement of pleural space infections andmalignant pleuraleffusions.2-17 Appropriate management using pleural drainagemay decrease hospitalization, prolonged systemic toxicity,ventilatory impairment, further spread of the inflammatoryreaction, and possiblemortality.6 Light and Sahn reported that

a pleural fluid pH of less than 7.1 defined the pleuraleffusion as complicated and predicted that pleural drainagewould be necessary to avoid pleural fibrosis and resolvepleural sepsis, whereas a pH ≥ 7.3 would predict resolutionwith systemic antibiotics alone.12,17 Jiménez Castro andcolleagues have demonstrated that pleural fluid pH has thehighest diagnostic accuracy for identifying complicatedparapneumonic effusions.11 The most recent AmericanCollege of Chest Physicians (ACCP) consensus panel on themedical and surgical management of parapneumoniceffusions recommends that pleural fluid pH is the preferred

I

NCMed J January/February 2009, Volume 70, Number 1

pleural fluid chemistry test and should bemeasured via bloodgas analyzer.6 In patients with a malignant pleural effusion, apleural fluid pH of less than 7.3 may suggest that the patienthas a limited life expectancy from the time of diagnosis andmay fail chemical pleurodesis.8,10,18-21 Although the accuratemeasurement of pleural fluid pH is relevant to the care ofpatientswith complicatedpleural fluid infections andmalignantpleural effusions, there has been little reported about the useand knowledge of this measurement by chest physicians.

Three methods with unique performance characteristicsare commonly used to measure pleural fluid pH: blood gasanalyzer (BGA), pH meter, and pH indicator stick.22,23 Chengand Lesho have demonstrated that themeasurement of pleuralfluid pH with a blood gas analyzer is the most accurate ofthese, but other methods are used widely.22,23 Chandler andassociates reported that 68% of hospital laboratories in thesoutheastern United States measured the pleural fluid pHwith either pH indicator stick or pH meterand not by BGA.24 In a similar nationalsurveyof 220hospital laboratories, Kohnandcolleagues also reported varied approaches:pH meter (35%), BGA (32%), and pHindicator stick (31%).25

The laboratory measurement of pleuralfluid pHwith any method other than a BGAposes problems for the practicing physician.If the sample is not measured by a methodthat is validated in the literature, then theresulting data may not be appropriate toguide clinical decisions. The use of pHmeteror indicator stick can overestimate pH.22

Thismay leadtoadiagnosticmisclassificationof the effusion, a potential underestimationof the gravity of the problem, and under-treatment of the condition. Furthermore, ifthephysicianbelieves that thesample isbeingmeasured by the standard method that hasbeen validated in the literature (BGA), but in fact it is not, thenan inappropriate clinical decision may be made.

The goal of this study was to determine the knowledge ofpracticing pulmonologists about the measurement of pleuralfluid pH by hospital laboratories and the actual methods usedtomeasure pleural fluid pH by their own hospital laboratories.

Methods

From July of 2006 to September of 2006we contacted 90pulmonaryphysicians inNorthCarolina, identifiedby registrationwith the North Carolina Medical Board and membership withthe American College of Chest Physicians (ACCP), via email,fax, or telephone. We then asked them to complete a surveyconcerning their use of pleural fluid pH in patients with pleuraleffusions and to report how their hospital laboratorymeasurespleural fluid pH from a list of three methods: pH indicatorstick, pH meter, or BGA. We then contacted the individualhospital laboratories (within 30 days of receiving the physician’s

responses) used by these pulmonologists and asked whatmethod they used to measure pleural fluid pH: pH indicatorstick, pH meter, or BGA. Each laboratory and physician wascontacted only once. This study was approved by the WakeForest University School ofMedicine Institutional Review Board.

Results

Thirty-one percent (28/90) of the surveyedNorthCarolinapulmonary physicians responded to our questionnaire andpracticed at 11 different North Carolina hospitals (100% of thehospitalswere contacted; 11/11), including 2 universitymedicalcenters. Physicians and hospitals were distributed across thestate (see Figure 1). Proportions of responses by physiciansand laboratories were calculated reported, and compared toone another (see Table 1). The responses to each question aresummarized below.

Do you order pleural fluid pH?Seventy-one percent (20/28) of respondents reportedthat they order pleural fluid pH and 28.6% (8/28) reportedthey do not.

To your knowledge, how does the hospital laboratorymeasure the pleural fluid pH: pH indicator stick, pHmeter, or through a blood gas analyzer?

Seventy-five percent (21/28) of responding pulmonologistsreported that their hospital laboratory measures pleuralfluid pH by BGA, 3.6% (1/28) by pH indicator stick, 3.6%(1/28) by pH meter, and 17.9% (5/28) did not know howtheir hospital measures the pleural fluid pH (see Figure 2).

Pleural fluid pHmeasurement by North Carolinahospitals

Eighteen percent (2/11) of the hospitals surveyed (one oftwo of the university medical centers) reported that theymeasure pleural fluid pH by BGA, 36.4% (4/11) by pHmeter, and45.5%(5/11) bypH indicator stick (see Figure2).

10

Figure 1.Number of North Carolina Hospital Laboratories andPulmonologists Surveyed Per Region


Accuracyof physiciansperceptionsofpleural fluidpHbyNorthCarolinahospitals

Fifty-sevenpercent (16/28)of the respondents had inaccurateperceptions of how pleural fluid pHwasmeasured by theirhospital laboratory, 25% (7/28) were accurate, and 17.9%(5/28) did not know how the pleural fluid pH is measuredby their hospital.

Of thephysicianswhoorderpleural fluidpH, 30%(6/20)had accurate knowledge of how their hospital measurespleural fluid pH (83% or 5/6 BGA; 17% or 1/6 pH indicatorstick), and 70%(14/20) had inaccurate perceptions of howpleural fluid pHwasmeasured.Most (18/20, or 90%)of thepulmonologistswho ordered pleural fluid pHperceived thatthe hospital laboratory was using a BGA, but 72% (13/18)were inaccurate in this belief. For these physicians (thosewho order pleural fluid pH and perceived themeasurementwas by BGA), the hospitals (n = 8) had varying approaches:24% (2/8) of the hospitals actually measured pleural pHwith a BGA, 37.5% (3/8) with a pH meter, and 37.5%(3/8) with a pH indicator stick.

Among the eight physicians who reported they do notorder pleural fluid pH, only one knew their hospital’sapproach (pH meter).

Discussion

Our survey has demonstratedthat the majority of respondingpulmonary physicians in NorthCarolina order pleural fluid pH, butthere is a substantial discrepancybetween the clinicians’ perceptionsof the method measurement ofpleural fluid pH by their hospitallaboratoriesand theactualmethod;only30%of theorderingpulmonaryphysicians knew themethod usedby their own hospital laboratory.Most of the surveyed physicians(75%) believed that the pH wasbeing measured by BGA (theapproach consistent with theliterature6,7,9-12,15-17,20,21) but of these,72% were mistaken about themethod used. To our knowledge,this is the first report of discordancebetweenpulmonologistperceptionsand the reality concerning themeasurement of pleural fluid pH.This implies that clinical decisionscould bemade based on data thatis not supported by the literature.Furthermore, our data is consistentwith previous reports thatlaboratories continue to usemethods other than BGA tomeasure pleural fluid pH.24,25

Cheng and colleagues established the accuracy of the BGAinmeasuring the pH of pleural fluid handled in the ideal fashion(anaerobicallywith rapidmeasurement) anddemonstrated thatboth pH meter and indicator stick significantly overestimatedthe pleural pH.22 The mean pleural fluid pH measured by BGAwas 7.42 ± 0.01 compared to the mean pleural fluid pHmeasuredby a pHmeter and indicator stick of 7.58 ± 0.02 and8.23 ± 0.06 respectively. Cheng also reported that the 95%confidence interval for the precision of the pH meter andindicator stick was ± 0.26 and ± 0.80 respectively.22 Since theclinically significant change in pleural pH is approximately0.3 pH units (pH 7.4 to < 7.1), neither the pH indicator sticknor the pHmeter are precise enough to be clinically accurate.Although other clinical indicators of complex pleuralpathophysiology are available and useful, if the pulmonologistis unaware or mistaken about the method of measurement, adiscordant pleural pH result can lead to confusion and the testwill not be cost effective. Yet, by our survey, a majority ofNorth Carolina pulmonary physicians place value in thismeasurement while theminority of pleural pHmeasurementsis done by the recommended method (BGA).

Eight of the 28 responding chest physicians reported thatthey do not use the measurement of pleural fluid pH to

Table 1.Pulmonologist Perception of pHMeasurementin 11 North Carolina Hospitals

Hospital Pulmonologists Perceived Actual pH Percentage ofsurveyed method measurement physicians who

of pH were correct inmeasurement their perception

of pHmeasurement

1 1 IS IS 100%

2 1a DNK MT 0%

3 3 BGA MT 0%

4 1 BGA MT 0%

5 2 BGA BGA 100%

6 1 BGA IS 0%

7 3 BGA IS 0%

8 1 BGA IS 0%

9 3 BGA BGA 100%

10 7b 5 BGA MT 14%1 MT1 DNK

11 5c 2 BGA IS 0%3 DNK

aThis physician did not order pleural fluid pH.bTwo out of these seven pulmonologists did not order pleural fluid pH.cNone of these pulmonologists ordered pleural fluid pH.

IS = Indicator stick DNK= Did not know BGA = Blood gas analyzer MT = pH meter


characterize pleural fluid. The reasonsfor the under use of this potentiallyhelpful test are unclear and mightreflect perceived technical difficultiesor inconvenience in anaerobic handlingof specimens; however we did notaddress this in our study. Additionally,three of these physicians (those that donot order pleural fluid pH) believed thattheir hospital laboratory used BGA tomeasurepleural fluidpH,whichsuggeststhat they may have had concerns otherthan the perceived inaccuracy of theapproach to measurement. One canspeculate that this may be due to theirreliance upon othermeasures, perhapssubstituting LDH or glucose instead ofpH, in characterizing complicatedpleural effusions or other undefinedfactors.6,9 Heffner and colleaguesreported that pleural fluid pH wasmeasured in 28 of 38 patients withcomplicated parapneumonic effusionsand in only 5 out of 10 patients who underwent “delayed”pleural fluid drainage.2 More information is needed regardingbarriers to physician’s use of pleural fluid measurements.

Interestingly, only 2 of our 11 surveyed hospitals in NorthCarolina use a BGA to measure pleural fluid pH. This isconsistent with Chandler’s finding that 32% of laboratories inthe SoutheasternUnited States used a BGA tomeasure the pHof pleural fluid.24 Selected laboratorieswe surveyed volunteeredseveral concerns, although itwasnot a routinepart of our formalquestioning. These included reports that the protein contentin the exudative pleural fluid possibly obstructed or damagedthe BGA (a belief reported by Lesho and Chandler).23,24Whileit is clear that frank pus should not be evaluated for pleuralfluid pH (nor should it be needed), it is unlikely that theprotein content alone can damage these machines since theprotein content of pleural fluid is less than whole blood.24,26

Additionally, some of the laboratories volunteered that themanufacturers warn that the BGA is validated only for wholeblood and that the measurement of pleural fluid pH by a BGAisnot FDA-approved (except for oneBGAbyRoche, theOMNI).The measurement of pleural fluid pH by a non-FDA approvedBGA is considered a complex test (defined by adherence tostrict guidelines for precision and accuracy testing) by theClinical Laboratory Improvement Amendments (CLIA). Furtherinformation is needed about barriers to BGA use by hospitallaboratories but one may relate to the cost effectiveness toperform a complex test.

There are several limitations to our study. The number ofpulmonologists we surveyed was small (28 of 90), and thesefindingsmay be biased by selective responses andmay not bea valid estimate of North Carolina pulmonologists or chestphysicians outside of North Carolina. However, our responserates are similar to those reported in literature.27 We did not

investigate why some pulmonologists do not order pleuralfluid pH. Further, we did not examine how the sample wascollected and if it is handled and processed in an anaerobicmanner, factors which influence the accuracy of the test.Venkatesh demonstrated that aerobic storage of pleural fluidresulted in a clinically important overestimation of pleuralfluid by pH meter and BGA of 0.14 – 0.16 pH units (p < 0.05).He felt that both anaerobic handling of the specimen andrapid measurement throughout the process (albeit difficult inreal practice) were the keys to accuracy especially if utilizing apH meter to measure pleural pH.28 We did not make a routinepart of our questioning to the hospital laboratories as to whythey use a particular method to measure pleural fluid pH asour goalwas to determine themethod usedby the laboratoriesand if the pulmonologist was aware of the method of pHmeasurement. Only pleural fluid pH measured by BGA hasbeen validated by clinical investigations.2,5-7,9-12,15,16,18-21,29

We found that themajority (75%) of pulmonologists eitherdid not know how pleural fluid pH was measured by theirhospital laboratory (17.9%) or had inaccurate perceptionsconcerning the measurement of pleural fluid pH by NorthCarolina hospitals (57%). Fundamentally, the clinical value ofa test is in its validation in a particular clinical scenario. Pleuralfluid pH is useful in the management of complex pleuraleffusions; however, its value is diminishedwhen it is measuredby methods other than a BGA which may lead to erroneousmanagement decisions especially if the clinician is unawareof the inaccuracy of the test when a BGA is not utilized. Thisrepresents a lost opportunity to improve the care of patientswithpleural effusions. If these findingsareconfirmed, thebarriersto more optimum practices by physicians and laboratoriesshould be identified and corrected. NCMJ

Figure 2.Comparison of Pulmonologist’s Perception of Pleural Fluid pHMeasurement by Their Hospital Laboratory and the Actual MethodUsed by Hospital Laboratories

REFERENCES

1 Halm EA, Teirstein AS. Clinical practice. Management ofcommunity-acquired pneumonia. N Engl J Med.2002;347(25):2039-2045.

2 Heffner JE, McDonald J, Barbieri C, Klein J. Management ofparapneumonic effusions. An analysis of physicians practicepatterns. Arch Surg. 1995;130(4):433-438.

3 Light RW, Girard WM, Jenkinson SG, George RB.Parapneumonic effusions. Am J Med. 1980;69(4):507-512.

4 Taryle DA, Potts DE, Sahn SA. The incidence and clinicalcorrelates of parapneumonic effusions in pneumococcalpneumonia. Chest. 1978;74(2):170-173.

5 Chavalittamrong B, Angsusingha K, Tuchinda M, HabananandaS, Pidatcha P, Tuchinda C. Diagnostic significance of pH, lacticacid dehydrogenase, lactate and glucose in pleural fluid.Respiration. 1979;38(2):112-120.

6 Colice GL, Curtis A, Deslauriers J, et al. Medical and surgicaltreatment of parapneumonic effusions: an evidence-basedguideline. Chest. 2000;118(4):1158-1171.

7 Davies CW, Gleeson FV, Davies RJ. BTS guidelines for themanagement of pleural infection. Thorax.2003;58(suppl 2):18-28.

8 Froudarkis ME. Diagnostic work-up of pleural effusions.Respiration. 2008;75(1):4-13.

9 Heffner JE, Brown LK, Barbieri C, DeLeo JM. Pleural fluidchemical analysis in parapneumonic effusions. A meta-analysis.Am J Respir Crit Care Med. 1995;151(6):1700-1708.

10 Houston MC. Pleural fluid pH: therapeutic and prognosticvalue. Am J Surg. 1987;154(3):333-337.

11 Jiménez Castro D, Díaz Nuevo G, Sueiro A, Muriel A,Pérez-Rodríguez E, Light RW. Pleural fluid parameters identifyingcomplicated parapneumonic effusions. Respiration.2005;72(4):357-364.

12 Light RW, MacGregor MI, Ball WC Jr, Luchsinger PC.Diagnostic significance of pleural fluid pH and PCO2. Chest.1973;64(5):591-596.

13 Light RW. Management of parapneumonic effusions. ArchIntern Med. 1981;141(10):1339-1341.

14 Lim TK. Management of parapneumonic pleural effusion.Curr Opin Pulm Med. 2001;7(4):193-197.

15 Poe RH, Marin MG, Israel RH, Kallay MC. Utility of pleural fluidanalysis in predicting tube thoracotomy/decortication inparapneumonic effusions. Chest. 1991;100(4):963-967.

16 Potts DE, Levin DC, Sahn SA. Pleural fluid pH in parapneumoniceffusions. Chest. 1976;70(3):328-331.

17 Sahn SA. The value of pleural fluid analysis. Am J Med Sci.2008;335(1):7-15.

18 Heffner JE. Diagnosis and management of malignant pleuraleffusions. Respirology. 2008;13(1):5-20.

19 Heffner JE, Heffner JN, Brown LK. Multilevel and continuouspleural fluid pH likelihood ratios for evaluating malignant pleuraleffusions. Chest. 2003;123(6):1887-1894.

20 Martínez-Moragón E, Aparicio J, Sanchis J, Menéndez R, CruzRogado M, Sanchis F. Malignant pleural effusion: prognosticfactors for survival and response to chemical pleurodesis in aseries of 120 cases. Respiration. 1998;65(2):108-113.

21 Sahn SA, Good JT Jr. Pleural fluid pH in malignant effusions.Diagnostic, prognostic, and therapeutic implications. Ann InternMed. 1988;108(3):345-349.

22 Cheng DS, Rodriguez RM, Rogers J, Wagster M, Starnes DL,Light RW. Comparison of pleural fluid pH values obtained usingblood gas machine, pH meter, and pH indicator strip. Chest.1998;114(5):1368-1372.

23 Lesho EP, Roth BJ. Is pH paper an acceptable, low-cost alternativeto the blood gas analyzer for determining pleural fluid pH?Chest. 1997;112(5):1291-1292.

24 Chandler TM, McCoskey EH, Byrd RP Jr, Roy TM. Comparisonof the use and accuracy of methods for determining pleuralfluid pH. South Med J. 1999;92(2):214-217.

25 Kohn GL, HardieWD.Measuring pleural fluid pH: high correlationof a handheld unit to a traditional tabletop blood gas analyzer.Chest. 2000;118(6):1626-1629.

26 Light RW. Pleural Diseases. 3rd ed. New York, NY: LippincottWilliams &Wilkins; 1995.

27 Sheehan KB. E-mail survey response rates: a review. J ComputMediated Commun. 2001;6(2). http://jcmc.indiana.edu/vol6/issue2/sheehan.html. Accessed January 7, 2009.

28 Venkatesh B, Boots RJ, Wallis SC. Accuracy of pleural fluid pHand PCO2 measurement in blood gas analyzer. Analysis ofbiases and precision. Scand J Clin Lab Invest. 1999;59(8):619-626.

29 Maskell NA, Gleeson FV, Darby M, Davies RJ. Diagnosticallysignificant variations in pleural fluid pH in loculatedparapneumonic effusions. Chest. 2004;126(6):2022-2024.

NCMed J January/February 2009, Volume 70, Number 1 13

Acknowledgements: The authors would like to thank RichardLight, MD, and Steven Sahn, MD, for their guidance and inputwith this research.

Financial Disclosure: This study did not receive any financialsupport, and the authors had no proprietary interest in any drug,device, or equipment mentioned in the submitted article.

he worldwide rise in the prevalence of diabetes mellitus(DM) has substantially affected women’s health care.

Up to 70% of women diagnosed with gestational diabetesmellitus (GDM) develop DM later in life.1 Less than half ofwomen with GDM will have a normal glucose tolerance test24 months after delivery.2 This has a substantial impact onfuture pregnancies in this high risk group, as rates of poorneonatal outcome are three to nine times higher in infantsborn to mothers with diabetes.3 Not unexpectedly, there aresigns that both the rate of GDM and postpartumDM are alsoon the rise.1,4,5 Women diagnosed with GDM have a 36-70%risk of developing GDM in subsequent pregnancies.6

Identifying this high-risk population sooner and providingcloser follow-up care could have a positive impact on theirlong-term health.7 Assessing glucose tolerance postpartumprovides an opportunity to target individuals that wouldbenefit from interventions such as exercise plans and dietarymodifications with the goal of stopping or delaying theprogression of diabetes.8 In fact, a recent large randomizedtrial showed a significant reduction in progression to diabetesin patients with glucose intolerance with either lifestylemodifications or metformin compared to placebo.9

Postpartum glucose tolerance testing is supported andrecommended by the American Diabetes Association (ADA)


Arthur M. Baker, MD, is a clinical fellow in the Division of Maternal-Fetal Medicine in the Department of Obstetrics and Gynecologyat the University of North Carolina at Chapel Hill. He can be reached at abaker2 (at) med.unc.edu.

Seth C. Brody,MD,MPH, is an associate professor in the Department of Obstetrics and Gynecology at the University of North Carolinaat Chapel Hill.

Kathryn Salisbury is a project manager at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina atChapel Hill.

Robin Schectman is an applications specialist at the Cecil G. Sheps Center for Health Services Research at the University of NorthCarolina at Chapel Hill.

Katherine E. Hartmann, MD, PhD, is an associate professor in the Department of Obstetrics and Gynecology at Vanderbilt UniversityMedical Center.

Abstract

Objective: To determine how frequently health care providers taking care of women with gestational diabetes mellitus (GDM) arescreening for postpartum glucose tolerance and what practice approaches they are using to care for women with GDM.Methods: A mailed survey assessed health care providers’ knowledge of GDM and practice patterns. Factors influencing practice

protocols for measuring glucose tolerance postpartum were identified.Results: Of 1,002 eligible North Carolina health professionals, 399 responded (40%); 327 of these (82%) were providing prenatal

and postpartum care and returned the completed surveys. Almost all providers (98%) screen for GDM, and the majority (97%) use the50-gram one-hour glucose challenge test. Only 21% of respondents always screen for diabetes mellitus (DM) postpartum. The mostcommon method for screening was the 75-gram two-hour glucose tolerance test (54%). The factors most commonly associated withfailure to screen were patients lost to follow-up, patient inconvenience, and inconsistent screening guidelines. A majority (59%) statedthat increased reimbursement would have little to no impact on their consistency in providing diabetic counseling.Conclusions: The rate of postpartum glucose tolerance testing is low in this study of providers of postpartum care. Several modifiable

barriers to screening were identified. There is a need for improved screening practices and early intervention that could help prevent thecomplications of DM and benefit subsequent pregnancies in this high risk population.Keywords: gestational diabetes mellitus; diabetes mellitus; pregnancy

PEER-REVIEWED ARTICLE

Postpartum Glucose Tolerance Screening inWomen with Gestational Diabetes in theState of North CarolinaArthur M. Baker, MD; Seth C. Brody, MD, MPH; Kathryn Salisbury; Robin Schectman;Katherine E. Hartmann, MD, PhD

T


in womenwhose pregnancies are complicated by GDM.10 TheAmerican College of Obstetricians and Gynecologists(ACOG) recognizes the importance of such testing but doesnot endorse any specific recommendations for follow-up.11

Despite this fact, there continues to be a large proportion ofwomenwithGDMthat fail to be screened for glucose tolerancein the postpartum period. In addition, the women that arescreened are not always testedwith the optimummethods.12,13

In this study, we will determine how often health careproviders are screening for postpartum glucose tolerance inwomenwith GDM and identify potential barriers to screening.

Methods

A list of 1,085 active, in-state practitioners (who providedprenatal care)was compiled frompublic access state licensurefiles and primary care association membership rolls in thestate of North Carolina. After excluding those who had retired,moved out of state, or had an incorrect address, a final list of1,002 practitioners was made. In 2005-2006, we mailed aquestionnaire to this group that included physicians andpractitioners in obstetrics and gynecology, family practice,andmidwiferywho had a complete address. Based on a reviewof the literature, the lead author developed a questionnairethat sought to determine screening status for patients withGDM. Itemswere then reviewed by coauthors for face validity.The finalized three-page, 28-item questionnaire requiredapproximately 10 minutes to complete. We remailed thesurvey to each eligible practitionerthat did not reply to the first request.Questionnaires were excluded fromanalysis if the answerswere incompleteor if the practitioner was not currentlyproviding prenatal and/or postpartumcare. A cover letter stressed theimportance of accurate reporting forthe purpose of improving the GDMscreening process in North Carolinawomen’s health clinics and privatepractice centers and to potentiallyincrease the number of perinatalservices provided to all women inNorth Carolina. No incentive wasoffered for completion of the survey.

The University of North CarolinaInstitutional Review Board approvedthe study. The survey was endorsedby the North Carolina chapter of theAmerican College of Nurse-Midwives,theNorth Carolina Academy of FamilyPhysicians, theNorthCarolina sectionofthe American College of Obstetriciansand Gynecologists, and the NorthCarolina Department of Health andHuman Services.

The first part of the survey consisted of questions regardingthe demographics of the practitioners, practice type, and thepatient population. Providers estimated both the proportionof their patients diagnosedwithGDMand the average numberof postpartum patients seen monthly. The goal of the surveywas to assess how frequently providers screened for DM inthe postpartum period in women diagnosed with GDM intheir practice. This was assessed utilizing a Likert scale from1 (never) to 5 (always). The rest of the survey had to do withhowproviders cared for their patientswithGDM. Specific areasaddressed in these questions concerned basic knowledge ofGDM and its long-term risks, screening methods for GDMand for postpartum glucose tolerance, its impact on futurehealth, and factors influencing the follow-up care.

Returned surveys were coded and double-entered by staff,and patterns in the missing observations were assessed. Weperformed descriptive statistics and univariate analysis. Thechi-square test assessed bivariate associations for the mainoutcome.

Results

Of the 1,002 eligible practitioners to whom surveys weremailed, 399 were returned completed for an overall responserate of 40% (see Figure 1). When asked whether or not theyprovide prenatal and/or postpartum care, 327 (82%)answered yes and were asked to complete the remainder ofthe survey. If respondents replied no, they were instructed

Figure 1.Participation in the North Carolina Collaborative Survey onGestational Diabetes Mellitus

to return the survey, leaving the remaining questionsunanswered. The average age of all respondentswas 48 yearswith 51% being male. Most respondents were white (90%).Onaverage, they completed their residency or clinical training17 years ago. When asked about their practice specialty, justover one-half (55%) stated it was obstetrics and gynecology.The next most common answers were midwifery (20%) andfamily practice (20%). The remaining 5% that respondedincluded maternal fetal medicine specialists,family planning providers, and otherwomen’s health-related clinicians. Aboutone-half (58%) of respondents stated theirpractice consisted of 2-10 providers.Withinthis subset, 87% report that their practiceis single specialty only. Table 1 summarizesdescriptions of the patient load for eachpractitioner.

Anoverwhelmingmajority of respondents(98%) report screening all pregnantwomen for GDM. Out of this number,97% use the 50-gram one-hour glucosechallenge test (50 grams of glucoseadministered in 150 mL of fluid with bloodsugar checked at one hour; cutoff ≥ 130mg/dL). Other methods included fastingand postprandial blood sugar, urine glucose,and glycosylated hemoglobin (HgA1c).Almost all respondents (96%) that screenfor GDM do so between 25-29 weeks. Halfof those surveyed (48%) indicated that6-10% of their patients were diagnosedwith GDM. When asked from whom theirpatients with GDM received care, 49%stated that it was their usual prenatal careprovider. One-fourth (25%) obtained aconsultation from a specialist beforeresuming care of their patients. Othercommon answers included transfer of careto either a specialist within their practice orreferral to a specialist outside of theirpractice. Additionally, 20%use a nutritionistor diabetes care team within their ownpractice to assist in management.

When asked about postpartum care ofpatientswithGDM, only 21%of respondentsalways screen for DM. Another 43%usuallyscreen, and 20% reported only screeningsometimes. Sixteen percent rarely or neverscreen. Primary specialty did not have animpact on the likelihood of postpartum DMscreening.

Of those that do screen for DM inwomen with a history of GDM, the mostcommon time to screen was four to sixweeks postpartum (45%) followed byseven to eight weeks (29%). Only 54% of

those who screen for DM postpartum use the 75-gramtwo-hour glucose tolerance test to screen patients in thepostpartum period that had GDM (75 grams of glucose withblood sugar checked fasting and then at two hours;cutoff ≥ 126 mg/dL for fasting and ≥ 200 at two hours).The other common screening methods reported includedrandom blood glucose (19%), postprandial glucose (11%),and the 50-gram one-hour glucose challenge test (8%).

Table 1.Patient Demographics Reported by Respondents

Frequency (N) Percent (%)

Postpartum patientsseen each month

<5 43 13

6-10 130 40

11-20 118 36

21-30 24 7

>30 12 4

Proportion of postpartumpatients onMedicaid

<20 114 35

21-40 78 24

41-60 69 21

61-80 43 13

>80 23 7

Proportion of African Americanpostpartum patients

0 3 1

<10 50 15

10-25 128 39

26-50 104 32

51-75 33 10

76-95 6 2

96-100 3 1

Proportion of Latinopostpartum patients

0 1 <1

<10 165 50

10-25 117 36

26-50 25 8

51-75 8 2

76-95 11 3

96-100 0 0



After the postpartum period in patients with GDM, 35% ofproviders assess for glucose tolerance every year, and 14%screen every three years. A high number of respondents (47%)indicated that they do not perform any routine screening.

Respondents were also asked what systematic approachthey use for postpartum follow-up of patients with GDM. Justover half (55%) responded that they primarily depend oncounseling by physician. Other approaches included amethodfor documenting screening in the medical record (21%) andcounseling by staff (14%).One-fifth (20%) reportedthat they did not have a specific approach.

When asked what proportion of women with ahistory of GDM develops GDM in a subsequentpregnancy using pre-set categories, a plurality(44%) believed it to be between 31-60%,whichwasfollowed by 1-15% (23%). Another 21% believedthat the number is greater than 60%. Respondentswere also questioned as to what percentage ofpatients with GDM will develop overt DM later inlife. A majority (58%) believed this number to beanywhere from 31-60%, with 13% stating thenumber was greater than 60%.

Finally, we identified factors that respondents feltinfluenced practice protocols for assessing glucosetolerance postpartum (see Table 2). Respondentswere asked to list all of the factors that affectedtheir practice of screening women with a history ofGDM. The most commonly reported factor wasthat patients were lost to follow-up (50%); the nextmost common factors were patient inconvenience(32%) and inconsistent guidelines (27%). Otherresponses includedpatient refusal (18%),patientcost(17%), and reimbursement (16%); 9% of thoseresponding stated that assessing glucose tolerancepostpartum was not considered necessary. Whenasked if increased reimbursement would affect the consistencywith which providers would provide diabetic counseling, 59%said it would have little to no impact while 19% said it wouldhave a substantial to very substantial impact.

Discussion

We found that in a diverse group of North Carolinapractitioners responsible for managing women with GDM,onlyone-fifth routinely screen for glucose tolerancepostpartum.Of those that do screen, only one-half do so with the 75-gramtwo-hour glucose tolerance test, the method recommendedby the ADA and supported by ACOG. These organizationsalso state that postpartum testing is best performed at leastsix weeks after delivery to allow the effects of pregnancy onglucosemetabolism to resolve.10,11Approximately three-fourthsof the respondents in our survey indicated that they screenbetween four to eight weeks postpartum. This low screeningrate conflicts with the acknowledgement by a majority of theproviders that the recurrence rate for GDM is high and a largenumber of patients will go on to develop overt diabetes.

The low rate of postpartum glucose tolerance assessment inpatients with GDMnoted in our study is consistent with severalother recent studies.12-14 Smirnakis and colleagues reportedthat 67% of the women with GDM in their observationalcohort study received some form of screening postpartum.However, only 37% of this population had the method oftesting recommended by the ADA (75-gram two-hour glucosetolerance test). In a retrospective cohort study by Russell andcolleagues, only 45% of women had postpartum glucose

tolerance testing consisting of a 75-gram two-hour glucosetolerance test or a fasting plasma glucose. Finally, Kim andcolleagues reported that only 38% of patients with GDMreported some form of glucose testing, with only 23% testedwith the current recommended methods.

Despite the low rate of postpartum glucose tolerancescreening inwomenwithGDMreportedbyour respondents, anoverwhelming majority (98%) screen for GDM in pregnancy.This is consistent with the finding of a study by Gabbe andcolleagues that found that 96% of their survey populationendorsed universal screening forGDM. In their study, 95%usedthe 50-gram glucose challenge test, which is recommendedby both the ADA and ACOG.15 Our respondents indicate thatthey use this test 97% of the time. In addition, almost all ofthose surveyed screen at the correct time of 25 to 29 weeksgestation.

There are several factors noted in our study that influencepostpartumglucose tolerance testing.The reasonmost frequentlygiven by our respondents was that patients did not return fortheir follow-up visit. This is supported by another one-third ofthose surveyed stating that patient inconvenience was an

Table 2.Factors Influencing Practice Protocols forAssessing Postpartum Glucose Tolerance

Factor Responding Percent (%)Providers (N)

Lost to follow-up 165 50

Patient inconvenience 104 32

Inconsistent guidelines 87 27

Patient refusal 59 18

Patient cost 56 17

Reimbursement 53 16

Practice too busy 43 13

Inadequate prenatal/ 42 13delivery information

Collaboration with specialists 42 13

Availability of continuing 37 11medical information on subject

Not considered necessary 31 9

Breast-feeding 8 2

REFERENCES

1 Kim C, Newton KM, Knopp RH. Gestational diabetes and theincidence of type 2 diabetes: a systematic review. DiabetesCare. 2002;25(10):1862-1868.

2 Nelson AL, Le MH, Musherraf Z, Vanberckelaer A.Intermediate-term glucose tolerance in women with a historyof gestational diabetes: natural history and potentialassociations with breastfeeding and contraception. Am J ObstetGynecol. 2008;198(6):699-707.

3 Yang J, Cummings EA, O’Connell C, Jangaard K. Fetal andneonatal outcomes of diabetic pregnancies. Obstet Gynecol.2006;108(3 pt 1):644-650.

4 King H, Aubert RE, HermanWH. Global burden of diabetes,1995-2025: prevalence, numerical estimates, and projections.Diabetes Care. 1998;21(9):1414-1431.

5 Dabelea D, Snell-Bergeou JK, Hartsfield CL, et al. Increasingprevalence of gestational diabetes (GDM) over time and bybirth cohort: Kaiser Permanente of Colorado GDM ScreeningProgram. Diabetes Care. 2005;28(3):579-584.

6 Bottalico JN. Recurrent gestational diabetes: risk factors,diagnosis, management, and implications. Semin Perinatol.2007;31(3):176-184.

7 Cheung NW, Byth K. Population health significance ofgestational diabetes. Diabetes Care. 2003;26(7):2005-2009.

8 Sattar N, Greer IA. Pregnancy complications and maternalcardiovascular risk: opportunity for intervention and screening?BMJ. 2002;325:157-160.

9 Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction inthe incidence of type 2 diabetes with lifestyle intervention ormetformin. N Engl J Med. 2002;346(6):393-403.

10 American Diabetes Association. Gestational diabetes mellitus.Diabetes Care. 2004;27(supp 1):88-90.

11 American College of Obstetrics and Gynecology. Clinicalmanagement guidelines for obstetrician-gynecologists. ACOGPractice Bulletin No. 30. Gestational diabetes. Obstet Gynecol.2001;98(3):525-538.

12 Smirnakis KV, Chasan-Taber L, Wolf M, Markenson G, Ecker JL,Thadhani R. Postpartum diabetes screening in women with ahistory of gestational diabetes. Obstet Gynecol.2005;106(6):1297-1303.

13 Russell MA, Phipps MG, Olson CL, Welch G, Carpenter MH.Rates of postpartum glucose testing after gestational diabetesmellitus. Obstet Gynecol. 2006;108(6):1456-1462.


important factor. This is in keeping with other studies thathave noted that attendance at the postpartum visit is a majorfactor in glucose testing.13,16 Employing strategies that improveattendance at the postpartum visit may increase testing ratesand provide another opportunity to counsel and educatewomen concerning the implications GDM can have on theirfuture health.

Inconsistent guidelines with respect to assessing glucosetolerance postpartum is also a significant barrier to testing.TheADAprovides recommendations andgives clear guidelinesas to methodology of screening and long-term follow-up inthese women.10 In ACOG’s current practice bulletin concerningGDM, no specific endorsement of such testing and follow-upis given.11 Other studies have called for ACOG to make formalrecommendations in this matter in hopes of increasing therates of testing.12However, there is evidence to suggest that thismay not help asmuch as onewould think. Clark and colleaguesshowed that even after the Canadian Diabetes Associationpublished specific guidelines for postpartumglucose toleranceassessment, the rate of testing did not improve in subsequentyears.17 Despite this conflicting evidence, it seems reasonablethat clearer guidelines could have a measurable impact ontesting rates.

We specifically addressed concerns regarding providerreimbursement in our study to assess its impact on postpartumglucose testing.Only 17%of respondents felt it was a significantfactor, and over one-half stated that increasing reimbursementwouldhaveminimal tono impact on theconsistencywithwhichthey provide diabetes counseling. Only one-fifth commentedthat thiswouldhaveasignificant impactwith respect toprovidingthis service. From the results of this survey, it is difficult toconclude whether or not increased reimbursement wouldhave a beneficial effect on postpartum glucose testing rates.

This study has several potential limitations. Our responserate is somewhat lowat slightly less than40%, andour findingsmay not reflect actual practice patterns of providers in thestate of North Carolina. The characteristics of nonresponderswere not available to this project, and these practitioners’practicesmay differ from those that responded. The responsesin this self-reported data may reflect the desire to providethe correct and accepted answer and may therefore actuallyoverestimate the true rate of screening for DM in thepostpartum state. Also, we decided to include all providersresponsible for providing care to womenwith GDM, includingfamily practitioners and midwives. However, despite thediversity of our respondents, the high rate of screening forGDM in pregnancy with the guidelines recommended byACOG and the ADA was similar to a large survey that onlyincluded obstetricians.15 The low rates of postpartum glucosetolerance screening that we report are also noted in severalother studies.12-14 The consistency of our findings with theseother studies indicates that our results may reflect actualpractice patterns.

The increasing rate of bothGDMandDMposes a significantthreat to the health of both pregnant and nonpregnantwomen. There is growing evidence that womenwithGDMarenot receiving optimum follow-up after delivery. Strategies toimprove postpartum glucose tolerance testing are needed.Further investigation iswarranted given that an earlier diagnosisof DM could reduce the complications of this disease inwomen. In addition, there is potential benefit to the futurepregnancies in this high-risk population. NCMJ

Funding: Funding for this study was received from an educationalgrant fromMatria Healthcare.


14 Kim C, Tabaei BP, Burke R, et al. Missed opportunities for type 2diabetes mellitus screening among women with a history ofgestational diabetes mellitus. Am J Public Health.2006;96(9):1643-1648.

15 Gabbe SG, Gregory RP, Power ML, Williams SB, Schulkin J.Management of diabetes mellitus by obstetrician-gynecologists.Obstet Gynecol. 2004;103(6):1229-1234.

16 Greenberg LR, Moore TR, Murphy H. Gestational diabetesmellitus: antenatal variables as predictors of postpartumglucose intolerance. Obstet Gynecol. 1995;86(1):97-101.

17 Clark HD, vanWalraven C, Code C, Karovitch A, Keely E. Didpublication of a clinical practice guideline recommendation toscreen for type 2 diabetes in women with gestational diabeteschange practice? Diabetes Care. 2003;26(2):265-268.


HEALTH REFORM IN NORTH CAROLINALessons from the Past and Prospects

for the FutureThomas C. Ricketts III, PhD, MPH

Editor-in-Chief, North CarolinaMedical Journal

“It is the intent of the General Assembly to: develop a universal health care program to provide all North Carolinaresidents access to quality health care that is comprehensive and affordable.”

House Bill 729, Ratified July 14, 1993

We are now entering a time when health reform has become a very popular if unresolved issue. In 2008,both presidential candidates made promises that they would bring significant change to the way we payfor and organize health care. Candidate McCain spoke of major changes in how insurance was to beregulated and health benefits taxed with the goal of ensuring that all Americans would be covered bysome form of insurance or would have a safety net system available to them. Candidate Obama had adifferent approach to achieving many of the same goals. The campaign discussions around health reformwere often accompanied by warnings to both candidates to avoid the failures of the early 1990s whenPresident Clinton tried to push comprehensive reform.

Meanwhile, several states have been pushing ahead with reforms of their own—Massachusetts haspassed a broad mandate, California considered but defeated one—however North Carolina is not amongthose considering comprehensive change. This may be the case because North Carolina, like the nation,thought seriously about major reform in the early 1990s but gave up on the effort, and that shift has keptus from trying again. In the current discussion of reform, especially given the focus in the presidentialcampaign, we ought to reflect on the past and learn from what was effective and produced genuinelypositive results. When state level reformers come together today, they spend a great deal of effort lookingto Massachusetts and California. But there is a lot to learn from our own experience in North Carolina.

Health reform in North Carolina in the 1990s was the product of a relatively small group of legislativeleaders who tried to capture the impetus of national reform efforts to change the way health care wasorganized, paid for, and delivered in the state. The North Carolina Health Planning Commission wascreated by the General Assembly at the close of the 1993 session and passed as Chapter 529 of 1993Session HB 729, the Jeralds-Ezzell-Fletcher Health Care Reform Act. The Commission was given a highprofile as it was chaired by Governor Hunt with Speaker Dan Blue and President Pro-Tempore MarcBasnight serving as vice-chairs. The other 13 members included Lieutenant Governor DennisWicker, andinfluential members of the Assembly including Senators George Daniel, James L. Forrester, Ted Kaplan,Beverly Perdue, and Sandy Sands along with House members Dub Dickson, Karen Gottovi, Joe Mavretic,RichardMoore, and ThomasWright. Secretaries Robin Britt of Human Resources and Jonathan Howes ofEnvironment, Health, and Natural Resources were also members of the Commission.

The Commission was charged by lawwith “developing a universal health care program to provide all NorthCarolina residents access to quality health care that is comprehensive and affordable.” The Commissionwas to create that plan and present it to the General Assembly in its 1995 session. There were somecaveats in the bill that made the implementation of a “universal health care program” contingent upon a“national mandate for universal coverage,” or appropriate waivers from the Employee Retirement IncomeSecurity Act (ERISA), Medicaid and Medicare rules, or if the General Assembly determined it couldimplement a program within existing law. Still, it operated under an expression of anticipated, broad scalereform of the health care system.

The mechanism for generating the plan for reform was to create 17 separate committees charged withdeveloping specific and actionable recommendations for the General Assembly. Those committees wereco-chaired by a full member of the Commission along with a member of the public or a recognized expertin state government. They were created to represent the wide range of stakeholders who would have tobe called upon to ensure the passage of system-wide reform legislation.

The Health Planning Commission made a number of specific recommendations that fell into seven majorcategories: (1) expanding coverage to the uninsured; (2) controlling rising health care costs; (3) expandingservices in rural and urban medically underserved areas; (4) changing the focus of the current healthsystem from a curative medical system to one that focuses on keeping people healthy; (5) ensuring highquality services; (6) establishing a data and information system capable of meeting the health informationneeds of the future; and (7) ensuring that the health needs of at-risk populations are met. There weremany specific recommendations included in the final reports of the 17 separate advisory committees thatmet during 1994.

The Commission delivered its final report in December of 1994, but the General Assembly it reported tohad a different party in control, new leadership, and no appetite for comprehensive reform. The electionof November 1994 changed the landscape for national health reform as well as reform in North Carolina.Still, the Commission was able to promote some substantive changes in North Carolina law and actuallyheld on through 1996 in a slightly revised form as the paradoxically renamed North Carolina Health CareReform Commission. That Commission was charged by the General Assembly in its 1995 session tobecome a body that would “…monitor, evaluate, address, and study a variety of issues relating to…thehealth care delivery system in North Carolina...with the goal of improving the health status of all NorthCarolina citizens.”

The first commission did generate positive legislative action, but it did so with an expectation that broaderchanges would come eventually. A general conclusion of the Health Planning Commission was that anyreformwould have to be incremental. For example, they recommended that a data council should be createdto coordinate the complex adoption of electronic medical records—one of many specific recommendationsthat did not result in action but is still discussed and relevant today.

There were recommendations that did find their way into legislation that eventually passed, includingexpansion of health insurance coverage for children up to 200% FPG (through Medicaid and then later,the NCHealth Choice program), expansion ofMedicaid coverage for the elderly and disabled up to 100%FPG, expansion of home and community based services to enable persons to remain in their home or incommunity-based settings, expanding portability of health insurance coverage in the group and non-groupmarket, tort reform (including pretrial screening by a qualified expert before filing a complaint), antitrustprotection for providers, and improvements for rural health access. These were largely adjustments tothe existing system and not what might be called broad reform.

Despite the fact that there was little actual reform legislation passed in 1994, the extensive hearings andworking sessions that resulted in the sweeping array of proposals for health system improvement wastestament to the utility of this form of participatory structure for giving useful guidance for policy. Whenthe Commission reported in the fall of 1994, it was anticipated that further changes would be made in thenext session of the General Assembly. However the 1994 election changed that landscape dramatically.

The “re-established” commission had a very different structure than the original body. The 12 membersof the new commission was appointed by the Speaker of the House and the President Pro-Tem of theSenate and included as co-chairs Carmen Hooker Buell, then a government affairs representative forCarolinas Medical Center, Zeno L. Edwards Jr, a state representative from Washington, North Carolina,and a dentist. The members were drawn from the House (3), the Senate (2), and major stakeholdergroups in health care in the state including the North Carolina Medical Society, Blue Cross and BlueShield of North Carolina, and the North Carolina Academy of Family Physicians.

continued on page 22


The Health Care Reform Commission chose to limit its meetings and the topics it would cover to a listthat included primary care, children and special populations, data collection, the Department of Health,rural health, allied health issues, network issues, and long-term care. These topics were discussed in amarket context as the Commission felt that their task was to provide advice and information to assistmarket forces to restrain increases in health care costs and improve access.

The Health Care Reform Commission submitted its final report on December 31, 1996 after receiving asix-month extension on its charter. That report included some broad recommendations, such as, “byJanuary 1, 2000, every child in North Carolina [should] have health insurance coverage,” to very specific,“state employees should be allowed to purchase group rate long-term care insurance with flex accounts.”The former recommendation has not yet been achieved but led to actions that would become part of theChildren’s Health Insurance Program, passed in 1998. The flex program recommendation eventuallybecame available via the State Teachers and Employees Health Plan.

Since 1996, the General Assembly has not embarked on any further broad scale legislation for healthcare delivery and financing but has instead tended to respond to national trends and specific state issues.As the new national administration begins to turn its attention to health financing reform, if not systemrestructuring, the General Assembly may find that it too wishes to address a broader set of issues in acoordinated way.What we learned from the organization and operation of the two commissions was thatthe broad scale involvement of over 300 citizens and leaders in the committee process could developrealistic proposals that could make it through the General Assembly. We also learned that these neededmore coordination and integration. There was not enough effort put into bringing all the specific partstogether. We also developed good baseline information about the problems that still face us: informationsystems were key in 1993 and remain so in 2009 we still are faced with a need to develop and make useof electronic health records and other forms of health information technology. We learned that changesin health insurance regulation, especially those that affected networks of providers, must be coordinatedwith the realities of the delivery system. We also learned that we must shore up resources in preventionand primary care to make our health system effective. Many of the hearings and testimony in the summerof 1993 and through 1994 will be germane and instructive in the coming months if North Carolina choosesto embark on a broad scale improvement of our health system. NCMJ


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IntroductionThomas C. Ricketts III, PhD, MPH;Christine Nielsen, MPH

Issue Brief: Substance Abuse in North CarolinaPam C. Silberman, JD, DrPH; Representative Verla Insko;Senator Martin L. Nesbitt Jr, JD; Dewayne Book, MD;Kimberly Alexander-Bratcher,MPH; Berkeley Yorkery, MPP;Jennifer Hastings, MS, MPH; Daniel Shive, MSPH;Jesse Lichstein, MSPH; Mark Holmes, PhD

COMMENTARIESDrug Addiction:A Chronically Relapsing Brain DiseaseDavid P. Friedman, PhD

Substance Abuse Screening and BriefIntervention in Primary CareSara McEwen, MD, MPH

Recovery-Oriented Systems of Care, theCulture of Recovery, and Recovery SupportServicesDonna M. Cotter, MBA

Making the Public Mental Health,Developmental Disabilities, and SubstanceAbuse SystemMore Accessible:An Invitation to RecoveryFlo Stein, MPH

The Emerging Role of Prevention andCommunity Coalitions:Working for the Greater GoodPhillip W. Graham, DrPH, MPH;Phillip A. Mooring, MS, CSAPC, LCAS

Substance Use Treatment Needs AmongRecent VeteransA. Meade Eggleston, PhD;Kristy Straits-Tröster, PhD, ABPP; Harold Kudler, MD

Physician Health vs. Impairment:The North Carolina Physicians Health ProgramWarren Pendergast, MD; Jim Scarborough, MDiv

Substance Abuse Treatment Continuum in theNorth Carolina Department of CorrectionVirginia Price

Drug Treatment CourtsKirstin Frescoln

Substance Abuse Services and Issues inCommunity Offender SupervisionRobert Lee Guy; Timothy Moose; Catherine Smith

The Physician’s Role in Treating Addiction as aDiagnosable and Treatable IllnessDewayne Book, MD

Adequacy of the Substance AbuseWorkforceAnna Misenheimer

Oxford Houses and My Road to RecoveryKathleen Gibson

“The failure toproperly recognizeand address the

needs of people withsubstance abusedisorders createsconsiderable

problems for theindividual, his or herfamily, employers,and society as a

whole.”

POLICY FORUMSubstance Abuse in North Carolina

IntroductionPOLICY FORUM:

Substance Abuse in North CarolinaA fine line exists between use and abuse, between attraction and addiction. When confronting

abuse of or addiction to legal substances—such as alcohol and nicotine—this fine line can be blurry anddifficult to detect. Crossing the line with illegal substances—such as cocaine or methamphetamines—is clearer to determine, as society has already deemed these substances too dangerous for any use atall, and there is a perception that use of these substances often leads to addiction.

Whatever the substance of choicemay be, the underlying biologicalmechanisms for the substance thatis abused and causes addiction remain the same. These substances create short-term perceived benefitsthat can generate dangerous behavioral change and long-term cravings and needs. The contributors inthis issue teach us that addiction is a chronic brain disease and that the time has come for us to leavebehind the myth that substance abuse is simply bad behavior stemming from moral failures.

Substance abuse poses a substantial public health challenge. It generates significant populationmorbidity and mortality for abusers as well as for others who are not users, such as victims of caraccidents where the driver was impaired. Like any other chronic disease, its initiation, progress, andtreatment are complex. Due to centuries of stigma and ignorance about the disease,much ofwhatmostpeople believe about substance abuse is incorrect.Wemust seek to understand the real causes and realsolutions of this problem if we are to prevent this disease and improve our health. It is not enough simplyto tell someone to “quit using.” The reality of someone with a substance abuse problem runs muchdeeper than sheer willpower or preventive policies. This is a significant challenge for health policy.

The consequences of livingwith a substance abuse disorder can be detrimental. Social consequencesmay include inability to hold a job, interpersonal conflicts, or legal troubles. Further, substance overusecan wreak havoc on the body, including doing permanent damage to the brain, heart, liver, and lungs.

Most observers see that we have an inadequate systemof care that exists for treating this condition.Not enough people are accessing treatment and often, when they do, they find themselves jumbled ina broken system of care. Our current system of care for people with substance abuse problems is largelydisjointed, underfunded, and ill-prepared to meet current need. The stigma associated with substanceabuse has significantly contributed to this problem. There are also economic factors that contribute tothe problem, as alcohol and tobacco are legal commercial products that support the livelihoods of asubstantial number of people.

This issue of the Journal takes a look at various aspects of this problem in North Carolina. We lookat the state as a whole but also provide insight into the unique needs for some high-risk populations:offenders, veterans, and those with mental illness. But the overriding message here is that this is adisease that can truly affect anyone.

Effective prevention and treatment programs do exist, andwe have invited experts and advocates todescribe how theywork andwhat they can do. There is a common theme to all of these solutions: thereis no one way that will reduce substance abuse to its irreducible minimum, and it takes a collaborativeapproach to keeping people from becoming abusers and recovering them from that state.

The lessons that are offered in our collection of articles are simple: we need to connect people withservices; we need to raise public awareness and personal understanding; we need to foster a culture ofrecovery that includes reducing stigma and blame. Taken together, these lessons offer a comprehensiveresponse to the face of addiction.

Thomas C. Ricketts III, PhD,MPH Christine Nielsen, MPHEditor-in-Chief Managing Editor



ddiction to alcohol, tobacco, and other drugs is a chronicillness, much like many of the other chronic illnesses

that health care professionals regularly treat. About one-half ofpeople with addiction disorders have a genetic predispositionto addiction, similar to people with asthma, diabetes, andhypertension.1-3Additionally, adherence and relapse rates aresimilar across these chronic illnesses. Researchersand health care professionals who study brainchemistry and addiction disorders recognize thataddiction is a chronic, relapsing disease with nocomplete cure. The goal of treatment should be tohelp the individual manage their chronic condition.Yet, as a society we often view addiction as amoral failure and blame the person for his or herdependence—making it difficult for people to seekcare. As a result, we have a system that is largelyunresponsive to the needs of peoplewith addictiondisorders.

The failure to properly recognize and addressthe needs of peoplewith substance abusedisorderscreates considerable problems for the individual,his or her family, employers, and society as a whole. In NorthCarolina, there are approximately 642,000 people age 12 orolder who used illicit drugs in the pastmonth (7.7%) andmorethan 1.6 million people (19.5%) who reported binge drinking.a,4

However, not everyone who uses alcohol or illicit drugs is

addicted to these substances. Nor does the occasional ormoderate use of some of these substances automatically leadto poor health outcomes. For example, some data suggest thatmoderate consumption of certain types of alcoholic beverages(e.g., a glass of red wine) may be protective for certain typesof health problems.5,6 Occasional use in moderate amounts

must be distinguished fromabuse or dependence. Abuse refersto misuse of a substance (usually in terms of frequency orquantity), which puts a person at heightened risk for adverseoutcomes such as injury,motor vehicle accidents, job loss, familydisruption, sexual assault, or a variety of medical conditions.

Pam C. Silberman, JD, DrPH, is the president and CEO of the North Carolina Institute of Medicine. She can be reached atpam_silberman (at) nciom.org.

Representative Verla Insko is a member of the North Carolina House of Representatives from District 56 in Orange County.

Senator Martin L. Nesbitt Jr, JD, is a member of the North Carolina Senate from District 49 in Buncombe County.

Dewayne Book, MD, is the medical director of Fellowship Hall in Greensboro, North Carolina.

Kimberly Alexander-Bratcher, MPH, is a project director at the North Carolina Institute of Medicine.

Berkeley Yorkery, MPP, is a project director at the North Carolina Institute of Medicine.

Jennifer Hastings, MS, MPH, is a project director and director of communications at the North Carolina Institute of Medicine.

Daniel Shive, MSPH, is a research analyst at RTI International.

Jesse Lichstein, MSPH, is a project director at the North Carolina Institute of Medicine.

Mark Holmes, PhD, is the vice president of the North Carolina Institute of Medicine.

“In North Carolina, 8.5% ofthe population age 12 orolder—more than 700,000people—are addicted toalcohol, drugs, or both.”

Substance Abuse in North CarolinaPam C. Silberman, JD, DrPH; Representative Verla Insko; Senator Martin L. Nesbitt Jr, JD;Dewayne Book, MD; Kimberly Alexander-Bratcher, MPH; Berkeley Yorkery, MPP;Jennifer Hastings, MS, MPH; Daniel Shive, MSPH; Jesse Lichstein, MSPH; Mark Holmes, PhD

ISSUE BRIEF

A

a Binge drinking is defined as drinking five or more drinks on the same occasion (i.e., at the same time or within a few of hours of eachother) on at least one day in the past 30 days.

Table 1.Estimates of North Carolina Population Age 12 or Olderwith Addiction Disorders who Receive Treatment

Number Percent

Dependence on or abuse of illicit drugs or alcohol in the past year 709,000 8.5%

Alcohol dependence or abuse in past year 551,000 6.6%

Of this, the number and percentage who report needing and receiving treatment 25,000 (4.5%)

Illicit drug dependence or abuse in past year 250,000 3.0%

Of this, the number and percentage who report needing and receiving treatment 25,000 (10.0%)

Source: Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services. National Survey onDrug Use and Health, 2005-2006. Estimates of North Carolina population based on 8.3 million people age 12 or older (2008).

b §10.53 of Session Law 2007-323.


Dependence or addiction connotes an emotional or physio-logical dependence on alcohol or drugs, where the individualloses control over his or her consumption despite the adverseand often very serious consequences in his or her life. InNorth Carolina, 8.5% of the population age 12 or older—morethan 700,000 people—are addicted to alcohol, drugs, or both.4

Despite the large number of people who report addictiondisorders, fewpeople inNorthCarolina are receiving treatment.The 2005-2006 National Survey of Drug Use and Healthreported that there were more than 550,000 people in NorthCarolina who reported alcohol dependence or abuse in thelast year, andmore than 250,000who reported illicit drug useor abuse (see Table 1).7,8 Yet fewer than 5% of all people age12 or older who reported alcohol addiction or abuse, and onlyabout 10% of the people addicted to illicit drugs, receivedtreatment.4 A slightly lower percentage of children age 12-17receive treatment (5% of those with alcohol addiction and9% of those who are addicted to illicit drugs). Even feweryoung adults ages 18-24 receive treatment (3% of peoplewith alcohol dependence or abuse and 7% of those whoreport illicit drug dependence).4

The failure to adequately reach and treat people withsubstance abuse disorders has significant societal implications.Alcohol and drug abuse was estimated to cost the NorthCarolina economymore than $12.4 billion in direct and indirectcosts in 2004.9 In 2005, more than 5% of all traffic accidentsin the statewere alcohol related, asweremore than one-fourth(26.8%)of all traffic-related deaths.10Almost 90%of prisonersentering the prison system have substance abuse disordersrequiring treatment, with 63% needing residential substanceabuse treatment services.11 Similarly, 43% of juveniles in thejuvenile justice systemare inneedof substanceabuse treatmentservices.12 Moreover, national data suggest that alcoholand/or drug abuse are contributing factors to the placementof 75% of children who enter the foster care system.13

The North Carolina Division of Mental Health,Developmental Disabilities, and Substance Abuse System

(DMHDDSAS), within the North Carolina Department ofHealth and Human Services, is charged with providing andensuring that substance abuse prevention and treatmentservices are available throughout the state. Most of the directprovision of publicly-funded services is managed by localgovernmental agencies, called Local Management Entities(LMEs). Overall, NorthCarolina spent $138million in 2006onpublicly-funded substance abuse services, a sum that left theNorth Carolina substance abuse system underfunded inrelation to other states.14

The North Carolina General Assembly asked the NorthCarolina Institute ofMedicine (NCIOM) to create a task forceto study these problems and to determine why the state’ssubstance abuse system was unable to serve more of thepeople in need.b The NCIOM Task Force on Substance AbuseServices was chaired by Representative Verla Insko, SenatorMartin L. Nesbitt Jr, JD and Dewayne Book, MD, medicaldirector for Fellowship Hall. It included 63 additional membersincluding legislators, state and local agency officials, substanceabuse providers, health professionals, consumers, educators,and other knowledgeable and interested individuals. The TaskForce met a total of 15 times over 16 months. A listing of TaskForce and Steering Committee members is included in theacknowledgement section at the end of this issue brief. Afull report detailing the work and recommendations of theTask Force is available on the North Carolina Institute ofMedicine’s website, www.nciom.org. In this issue brief, priorityrecommendations of the Task Force are presented in bold.

Comprehensive System of Care

As noted above, manyNorth Carolinians use, abuse, or aredependent onalcohol, tobacco, or other drugs. Somearealreadyphysically or psychologically addicted, while others engage inrisky or abusive behaviors thatmay later result in an addiction.Reducing substance use, abuse, and dependence requires acomprehensive system of care that starts with prevention,

offers early intervention services beforepeople become dependent, provides a rangeof treatment options that can appropriatelyaddress a person’s needs, and includesrecovery supports to help people withaddiction disorders manage their chroniccondition (see Figure 1).

PreventionA comprehensive system of care should

begin with prevention and should focus onyouth and adolescents. These individualsare particularly susceptible to addictiondisorders, as the prefrontal cortex region ofthe brain—the part of the brain associatedwith long-term decision-making and theability to balance trade-offs—does not fullydevelop until around age 25. Early use oftobacco and/or alcohol can impact thestructure and functioning of the developing brain.15,16 DavidFriedman discusses the impact of substance abuse on braindevelopment in this issue of the Journal. Studies show that ofthe adults who reported alcohol abuse or dependence in thelast year, approximately one-sixth (14.7%) first began usingalcohol at age 14 whereas less than 3% first began usingalcohol after age 21.17 Similarly, adults who first smokedmarijuana at age 14 or younger were more likely to reportbeing addicted to illicit drugs (15.9%) than were those whofirst smoked marijuana after age 18 (2.7%).17

Targeting youth and adolescents with evidence-basedprevention strategies should be a top priority for the state.North Carolina high school students reported in the 2007Youth Risk Behavior Survey that almost 40% of high schoolstudents had at least one drink in the last 30 days, more than20% reported binge drinking, and almost 20% have usedmarijuana in the last month.18 Further, a sizable proportion ofmiddle school students have also used these substances. Inthe 2007Youth Risk Behavior Survey, 33.6%of North Carolinamiddle school students reported having drunk alcohol (morethan a few sips) and 11.9% of middle school students reportedever having used marijuana.19 To be effective, communitiesshould developmultifaceted prevention efforts that target thegeneral population (“universal”), people at increased risk(“selective” populations), and people who have already begunto use or misuse tobacco, alcohol, or other drugs (“indicated”populations). The state has already implemented a similarmultifaceted approach to reduce underage smoking.Although youth smoking is still far too high, the smoking ratehas declined in recent years. Smoking among high schoolstudents has declined from 27.8% in 2001 to 19% in 2007.20,21

There has also been a decline in smoking among middleschool students. The state can build on these strategies by

targeting efforts to reduce the use of tobacco, alcohol, andother drugs among youth. The Task Force recommendedthat the General Assembly provide funding to pilot sixcomprehensive community-wideprevention efforts, prioritizingefforts to reach children, adolescents, young adults, and theirparents. The communities must involve multiple communitypartners including: schools, community colleges, universities,LMEs, public health, social services, juvenile justice, andother community groups.Communities that are selectedmustconduct a local needs assessment to prioritize preventiongoals and develop a plan to implement a mix of evidence-based prevention programs, policies, and strategies aimed atdelaying initiation and reducing the use of tobacco, alcohol,and other drugs among children, adolescents and youngadults.c The Task Force also recommended funding to expandcampusand community coalitions aimedat reducingunderagedrinking. Phillip W. Graham and Phillip A. Mooring describesuccessful community-based prevention campaigns in theircommentary.

Public policies aimed at reducing youth smoking or drinkingcan also help support broader community-based preventionactivities, asboth tobaccoandalcohol canbeprecursors tootherillegal drug use.22 Increasing the tax on tobacco products andalcohol has led to decreased consumption of these substances,particularly among youth who are more price-sensitive. Thus,the Task Force recommended that North Carolina increasethe cigarette tax and the tax on other tobacco products to thenational average, increase the excise tax on malt beverages(including beer), and periodically update the taxes for tobaccoproducts, malt beverages, and wine. Funding generated fromthese increased taxes should be used for prevention programsaimed at changing the cultural norms to prevent initiation, toreduce use, and to help people stop using tobacco, alcohol

Figure 1.Comprehensive Substance Abuse Services System

c SAMHSA has a registry of evidence-based programs (NREPP) that is searchable based on targeted populations, intervention points, andtypes of evaluation studies. The information is available at http://www.nrepp.samhsa.gov.


d These data are based on NCIOM calculations using 2005 MEPS, Agency for Healthcare Research and Quality. Substance abuse visits aredefined as visits for people with a substance abuse diagnosis using ICD-9 codes 303, 304, or 305. This estimate is low, as both patientsand providers may face incentives to use diagnosis codes other than substance abuse.

e Subsequent to the release of the interim report from the NCIOM Task Force on Substance Abuse Services, Congress enacted a mentalhealth parity bill. This legislation, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, was partof the Emergency Economic Stabilization Act of 2008, Public Law 110-343 codified at 29 USC §11815a, 42 USC §300gg-5. The new lawrequires businesses of 50 or more employees to provide the same coverage of mental health and substance abuse services as is provided forother illnesses—if the employer offers a plan with any coverage of mental health or substance abuse services. However, state mental healthparity applies to all health insurance plans of any size. NCGS § 58-51-50; 58-65-75, 58-67-70. Similar state substance abuse parity lawsshould be enacted to extend parity to groups of less than 50.


and other substances. The Task Force also recommendedprohibiting smoking in all public buildings in order to furtherreduce cigarette smoking and exposure to secondhand smoke.

Early InterventionComprehensive prevention efforts will help reduce the

number of people who use, abuse, or are dependent ontobacco, alcohol, and other drugs. However, it is unlikely thata comprehensive prevention effort will eliminate all abuse ofthese substances. Thus, we also need to develop earlyintervention programs to target the occasional user beforethey become dependent on these substances.

Because of the stigma associatedwith addiction disorders,many people with problems are reluctant to seek care fromspecialized substance abuse professionals. In contrast, visitinga primary care practice does not carry the same social stigma.Nationally, more than one-half of the US population visited aprimary care provider in one year, compared to less than 1%of people who seek care for substance abuse services fromoffice-based providers.d Primary care providers need to beable to identify both people with and at-risk of addictiondisorders so they can appropriately treat their underlyinghealth condition. Certain drugs that are appropriate to thegeneral population are contraindicated for peoplewith addictiondisorders. Primary care providers are well situated to screenpeople to identify those who are using tobacco, alcohol, andother drugs, and to provide counseling and brief interventions,includingmedication assisted treatment. There aremany newforms of medication management that are appropriate forpeople with substance use disorders, such as methadone,buprenorphineandnaltrexone forpeoplewithopiodaddictions,or disulfiram, naltrexone, and acamprosate for people withalcohol addictions.

Substance abuse screening, brief intervention, and referralto treatment (SBIRT) has been studied for over 20 years in anumber of populations and settings and has been found to beeffective. SBIRT has been used in rural and urban primary carepractices, emergency departments, federally-qualified healthcenters, public health departments, and school-based healthcenters, and has been successful in helping reduce consumptionamong people who abuse alcohol and/or illegal drugs.23-26

New federal monies are providing grants to study theeffectiveness of SBIRT in prescription drug abuse.

The SBIRTmodel is similar inmanyways to recommendedclinical guidelines to screen and counsel people who use

tobacco products.27Under SBIRT, providers screen patients todetermine the severity of their use of alcohol or other drugs,provide brief counseling for those who are not yet addicted,and refer others into appropriate levels of substance abusetreatment services. The success of this model is contingent onthree key factors: (1) trained primary care providers or otherswho can appropriately screen, provide brief interventions, andwhen necessary, refer to specialty treatment; (2) accessiblesubstance abuse providers who can provide an array oftreatment services and recovery supports for people withmore extensive needs; and (3) coordination of care and abi-directional flow of information between primary careproviders and qualified substance abuse professionals. In hercommentary, SaraMcEwen discusses the elements needed tosuccessfully implement SBIRT.

To encourage early intervention, the Task Forcerecommended that the General Assembly appropriate$1.5 million in recurring funds to DMHDDSAS to work withother appropriate organizations to educate health careprofessionals about the SBIRT model. This would includeeducation on substance use disorders, screening tools, briefintervention/motivational counseling, referral, and treatmentoptions.The initiative could involve a range of primary care andother ambulatory care providers. The focus, however, would beto involveprimarycareproviderswhoparticipate inCommunityCare of North Carolina to facilitate the development of morecomprehensive medical homes that integrate physical health,mental health, and substance abuse services. Primary careprofessionals would be trained to use evidence-based screeningtools, offer counseling and brief intervention, and referpatients to more intensive substance abuse services whenappropriate. In addition, the Task Force recommended thatpublic and private payers/insurers pay for substance abuseservices in parity with other illnesses, as well as pay forscreening and brief intervention in different health caresettings.e The state, local LMEs, and other partners shoulddevelop systems that facilitate bi-directional transitions andcoordination of care between the primary care providers andsubstance abuse providers.

Recovery-Oriented System of CareWhile prevention and early intervention will be sufficient

to help reduce the number of people with addiction problems,there will be some people who need more intensive services.In most state level estimates of alcohol and drug use (2005-

2006), 8.5% of North Carolinians age 12 or older reportedthat they abused or were addicted to alcohol or drugs.28 Yetfew of these individuals receive treatment. Several studiessuggest that the primary reasons people fail to seek or stay intreatment has more to do with the system’s inability to meetthe client’s needs rather than the individual’s lack of desireto seek help.8,29-33 Focus groups conducted in two counties inNorth Carolina (Dare and Rockingham) reached similarconclusions.34

NorthCarolina needs to create a recovery-oriented systemof care that includes a comprehensive array of substanceabuse services and recovery supports needed to meet theclinical needs and desires of the clients. A recovery-orientedsystemof care beginswith screenings, assessments, and briefintervention services but also offers a range of specializedsubstance abuse services for peoplewithmore severe addictiondisorders. These services include outpatient services,medication management, intensive outpatient and partialhospitalization, clinically-managed low-intensity residentialservices, clinically-managed medium-intensity residentialtreatment, inpatient services, and crisis services (includingdetox). Dewayne Book discusses the array of services andmedicationmanagement that is needed to effectively addressunderlying addiction disorders.

Many individuals with addiction disorders will also need anongoing support system to help them manage their addictiondisorders, including case management, relapse prevention,self-help, and support groups. This is similar in concept tochronic disease management provided to people with chronicillnesses. In addition to these services, some people withsevere addiction disorders need other services to helpaddress the adverse consequences resultant from years ofaddiction. People who have achieved sobriety may soonreturn to alcohol or drugs if they also fail to address issuessuch as homelessness, loss of employment, and/or marital orfamily strife. Thus, a recovery-oriented system of care shouldinclude linkages to a broader array of services such asemployment services or job skill training for people who losttheir jobs, or housing for homeless individuals. Othersmay alsoneed help with family or marital counseling in order to stay inrecovery.DonnaM.Cottermore fully explains recovery-orientedsystems of care in her commentary, and Kathleen Gibsondescribes her personal path to recovery in her commentary.To ensure that these services are available statewide, theTask Force recommended that the state develop a planorganized around a recovery-oriented system of care thatensures an appropriate mix of services and recovery supportsis available throughout the state for adults and adolescents.

Our current publicly-funded system of care includes someof the elements needed for a recovery-oriented systemof care.Prior tomental health reform, area programs (nowcalled LocalManagement Entities or LMEs) provided services directly.After reform, LMEs stopped providing these services directly.Instead, LMEs contract with local substance abuse providersto provide services. LMEs are responsible for ensuring thatindividuals obtain services and that they receive services at

an intensity level appropriate to their needs. Yet mostindividuals who need services are not able to access them.LMEs serving the highest percentage of the estimated needserved 11% of adults and a similar percentage of children(fourth quarter, SFY 2008), whereas the LMEs serving thelowest percentage of estimated need only reached 5% ofadults and 4% of children.35

Not only do LMEs assist few of the people with addictiondisorders, state data show that many of the people who seekcare through LMEs are not receiving it within the appropriatetime standards. For example, individuals who need emergentcare should be able to access it within two hours of first seekingtreatment, urgent care within 48 hours, and routine care within14 calendar days.

Whilemostof theLMEsensure thatpeopleneedingemergentor urgent care receive treatment within the appropriate timestandards, the LMEs have only a limited number of substanceabuse providerswho are actively engaging people in treatment(see Table 2). For example, individuals should receive foursubstance abuse visits within the first 45 days of initiatingcontactwith the system. The state has established performancetargets to ensure that at least 50%ofpeople receiving substanceabuse services through the LMEs receive the appropriatenumber of visits during this timeframe. Yet only six of the 24LMEs that reported data provide four visits within the first 45days to at least 50% of their clients. Some only meet thisstandard with as few as 27% of their clients. Studies showthat people who stay in active treatment for longer periods oftime have better treatment outcomes.36-39

The state’s data suggest that people are not activelyengaged for appropriate periods of time, and that consumersgenerally receive low-intensity services. For example, manypeople in North Carolina are receiving individual or grouptherapy services immediately after entry into the system. Thislevel of treatment is not appropriate by itself for people withdiagnosable addiction disorders, most of whom need someperiod of stabilization to address their addiction disorder. Amore appropriately balanced system of care would ensurethat people with addiction disorders immediately enter detoxor other residential treatment program, or receive intensiveoutpatient services. Individual or group therapy services maybe appropriate after the person has received more intensiveservices, if provided in conjunction with other services suchas medication assisted therapies. In her commentary, FloStein focuses on ways to make the publicly-funded substanceabuse system more accessible.

There are barriers in the current system thatmake it difficultfor LMEs to appropriately engage people with addictiondisorders. The lack of availability of a well trained workforce inmany parts of the state hampers the delivery of appropriateservices. Some LMEs face challenges finding providers willingto participate in the public system, given the funding levelsand administrative complexities. Other states have begun toimplement performance-based incentive contracts toimprove the capacity of the substance abuse system.40,41 Toaddress this concern, the Task Force recommended that


DMHDDSAS develop performance-based incentive contractsfor LMEs to use with local substance abuse providers. Theperformance-based contracts should include incentives foractive engagement, consumer outcomes, fidelity with evidence-based or best practices, client perception of care, and programproductivity.

Specialized Services for SubpopulationsIn addition to the services offered to the general public with

substance abuse disorders, other services are available to certainsubpopulations. Specialized services have been developed for:

juvenile and adult offenders in the criminal justice system,adults in workforce settings, adults who are receiving WorkFirst training and services or who are involved in the ChildProtective Services system, and active and returning veteransand their families.

Someof the judicial districts across the state have developedspecialized drug treatment courts to address the underlyingsubstance abuse needs of people who appear in court. Forexample, there are currently 12 family drug treatment courtsacross the state. These courts oversee child abuse and neglectcases inwhich parents have either lost custody of their children

Table 2.Standards and Achievement of Care in LMEs in North Carolina(SFY 2008, 4th Quarter)

Best Practices Meeting Percentage of Number of(State Required People who LMEsMeetingEstablished Treatment Received DMHDDSASPerformance Guidelines Recommended PerformanceTargets) [1] (Average Treatment Targets

LMEs) (LMEs)Timely access to careNeeding emergent care (statewide, 19% Within 2 100% 88-100% 22of people who seek services determined hoursto need emergency care)[2] (100%)Needing urgent care (statewide, 15% of Within 48 79% 13-100% 9people who seek services determined to hoursneed urgent care)[2] (88%)Routine care (statewide, 62% of people Within 14 68% 28-90% 13who seek services determined to need calendarroutine care)[2] days (69%)Active participation in treatment, retentionNumber of visits when care initiated Individuals receive 62% 36-82% 3

2 visits within14 days (71%)Individuals receive 46% 27-63% 64 visits within45 days (50%)

People discharged from Alcohol Drug ReceiveAbuse Treatment Centers (ADATC) community- 23% 0-53% 5receiving care in community based service

within 7 days ofdischarge (36%)

Table Notes: [1] Best practices for timely initiation of care have been adopted from the Healthcare Effectiveness Data and Information Set(HEDIS) performance measures. The best practices for active participation in treatment were adopted from theWashington Circle PublicSector Workgroup. www.washingtoncircle.org. The performance targets are set by the Division of Mental Health, DevelopmentalDisabilities, and Substance Abuse Services to emphasize high priority areas, while trying to be realistic about what can be achieved in asingle year. The goal is to continuously raise these targets as statewide performance increases. Over time, DMHDDSAS plans to establishbest practice benchmarks.[2] Timely access to care includes access for people with substance abuse problems, mental health problems, and developmental disabilities.Timely access measures are based on LME self-reported data. These data are not subject to external verification as there are no secondarydata collected at the state level that records when the person first sought assistance. With other data, the state calculates the percentagesbased on claims data.


f There are four VA medical centers, three outpatient clinics, six community-based outpatient clinics, and five Vet Centers in NorthCarolina. The VA medical centers are located in Asheville, Durham, Fayetteville, and Salisbury. The outpatient clinics are located inCharlotte, Hickory, andWinston-Salem. There are six community-based outpatient clinics located in Durham, Greenville, Jacksonville,Morehead City, Raleigh, andWilmington. In addition, there are five Vet Centers located in Charlotte, Fayetteville, Greenville, Greensboro,Greenville, and Raleigh.

g NCGS 90-113.30.

or are at risk of losing custody due to underlying addictiondisorders. As one of the conditions of reunification, parentsmust agree to drug treatment and intensive monitoring.Similarly, adult drug treatment courts currently operate in 21counties. These courts oversee the treatment of criminaloffenders with addiction disorders who have been convictedof intermediate sanctions. As with the family drug treatmentcourts, offenders must participate in active treatment, besubject to random drug tests to determine compliance, andmeet other court ordered requirements in order to stay out ofprison. Kirstin Frescoln discusses the role of drug courts andchallenges they face in her commentary.

In order for drug courts to be successful, the parents orcriminal offenders must have access to available treatmentservices. Further, probation officers and/or Social Services staffmust be available to monitor the individuals’ compliance withthe treatment regimen and other court ordered requirements.Therefore, the Task Force recommended that whenever theGeneral Assembly expands funding for additional drugcourts, that it also provide funding for additional treatmentservices and needed staff.

Approximately 90% of all prisoners entering the prisonsystem need substance abuse services, and 63% needinpatient substance abuse services.42 The Division ofAlcoholism and Chemical Dependency offers different levelsof substance abuse services to prisoners, including outpatientand residential treatment. However the North CarolinaDepartment of Correction is only able to provide services toapproximately one-third of the prisoners who need substanceabuse treatment. Studies have shown that prisoners whoreceive treatment for appropriate lengths of time are lesslikely to be repeat offenders.36-39 Further, offenders who arereleased on probation or parole need substance abuse servicesand ongoingmonitoring. TheTreatmentAccountability for SaferCommunities (TASC) program offers screening, assessment,and care management services for offenders with mentalhealth or substance abuse services who have been placed onprobation or released back into the community. TASC stafflink these offenders to appropriate treatment services andwork with probation officers to ensure that they stay in activetreatment. But as with other services, TASC is unable to serveall those in need. Last year (SFY 2008), TASC served morethan 18,000 people; however there may be as many as75,000 people on probation who need TASC services.Additional funding will be needed to expand TASC services tomore people on probation. Virginia Price provides moredetailed information about available services and the gaps intreatment availability for incarcerated adult offenders in her

commentary. Robert Lee Guy, TimothyMoose, and CatherineSmith discuss substance abuse issues for those on probationand parole in their commentary.

ManyActiveDuty and returningmilitary personnel also useor abuse alcohol and other drugs. North Carolina currently hasthe fourth largest concentration of military personnel in thecountry.We havemore than 100,000Active Duty personnel inour seven military bases or deployed oversees and another11,500 soldiers, marines, and airmen who serve in theNational Guard or Reserves. In addition, there are more than750,000veteranswho live inNorthCarolina.Almost one-fourthof all Active Duty military personnel and returning NationalGuard report alcohol dependence.

The Veterans Administration offers some services toreturning veterans, but veterans must go to one of the 22different Veteran Affairs (VA) medical centers or clinics toreceive these services.f These services are not sufficient tomeet the needs of all returning Operation EnduringFreedom/Operation Iraqi Freedom (OEF/OIF) personnel,particularly for those who are not located close to one ofthe VA centers. The state and federal government havecollaborated with other community partners to create broadersystems of care for returning veterans and their families,includingmentalhealthandsubstanceabuseservices.A.MeadeEggleston, Kristy Straits-Tröster, and Harold Kudler describethe services available through the VA and through this broadercommunity collaboration in their commentary. One of thegoals of the broader state-federal-local partnership is tocreate awareness and inform community practitioners aboutthe behavioral health needs of returning veterans and theirfamilies. However more effort is needed to ensure thatcommunity health professionals check returning veterans andtheir families for depression, substance abuse disorders, orpost-traumatic stress disorder.

Workforce

North Carolina needs an adequate supply of qualifiedsubstance abuse providers in order to be able to provideneeded treatments and recovery supports. Over the last 15years, the North Carolina General Assembly has passed severalbills to enhance the skills of substance abuse professionals. In1994, the General Assembly gave the North CarolinaSubstance Abuse Professional Practice Board (NCSAPPB) thestatutory authority to credential different types of substanceabuse professionals. Then in 2005, the General Assemblyrequired substance abuse professionals to have appropriatetraining and credentials (licensure, registration, or certification)


h This is a conservative estimate, as DMHDDSAS only anticipates that approximately 40% of youth and 48% of adults who need serviceswill actually seek services through the public system.

i Physicians, nurse practitioners, physician assistants, and certain other licensed health professionals can also provide treatment, but availabledata suggest that few of these professionals do so. Data from the Health Professions Data System showed that 0.5% or less of the physicians,nurse practitioners, and physician assistants report that they practice addiction medicine or addiction psychiatry as their primary orsecondary specialty area, and only about 0.2% of registered nurses report drugs or alcohol as their major clinical practice area. NorthCarolina Health Professions Data System, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill,with data derived from the North Carolina Medical Board, 2008. Data are not available about the number of licensed clinical social workers,psychologists, or psychology associates who practice in the addictions field.


from the NCSAPPB.g Currently, the NCSAPPB offers sevendifferent types of substance abuse credentials, based on theperson’s education, hours of supervised experience, andsuccessful completion of an exam: Licensed Clinical AddictionSpecialists (LCAS); LCAS-Provisional (LCAS-P); CertifiedClinical Supervisor (CCS); Certified SubstanceAbuse Counselor(CSAC); Certified Substance Abuse Prevention Consultant(CSAPC); Certified Substance Abuse Residential FacilityDirector (CSARFD); and Certified Criminal Justice AddictionsProfessional Credential (CCJP). People who are recognized bythe board as a LCAS or CCS can practice independently andbill third-party payers. The other substance abuse providerscanprovide direct services to individuals under the supervisionof another licensed substance abuse professional. AnnaMisenheimer describes the state of the North Carolinasubstance abuse workforce in her commentary.

In addition to the substance abuse professionalscredentialedby theNCSAPPB, other health care andcounselingprofessionals can provide substance abuse services if allowedwithin their scope of license. For example, physicians, nursepractitioners, physician assistants, licensed clinical socialworkers, psychologists, licensedmarriage or family therapists,or licensed professional counselors are authorized under theirlicensure laws to provide substance abuse services. Substanceabuse, addiction, and dependence do not escape the healthprofessional community. Warren Pendergast and JimScarborough discuss a unique program for health professionalsneeding substance abuse services in their commentary.

It is very difficult to ascertain the total number of peopleproviding addiction services because of the different types ofpeople who can provide services as part of their independentlicensure, or licensure under the supervision of LCAS, CCS,clinical supervisor intern (CSI), or physicians. Nonetheless,available data about people licensed by the NCSAPPB indicatesignificant disparities in the availability of qualified substanceabuse professionals. Eight counties lack any licensed or certifiedsubstance abuse counselors.43 In the other counties, the ratioof peoplewhoareexpected to seek services in thepublic systemper substance abuse clinician varies from 1,465 people perone clinician in Pasquotank County to 30:1 in Polk County.h

Although many people cross county lines to seek services,this wide disparity in the availability of qualified substanceabuse counselors suggests a significantworkforce shortage inmany areas of the state.i The Task Force heard from manyspeakers about the shortage of qualified substance abuseprofessionals in our state. Thus, the Task Force recommended

that the state create a substance abuse professional fellowsprogram, similar to the teaching fellows programs.TheGeneralAssembly should appropriate funds to start a scholarshipprogram for individuals seeking two-year, four-year, or master’sdegrees in the substance abuse field. In return for the funding,students would be expected to work in North Carolina in apublic or nonprofit substance abuse program for one year forevery $4,000 in scholarship funding.

As the Task Forcemembers learned over the last 16months,we cannot overestimate the need to reform our currentsubstance abuse system. Our failure to adequately prevent,treat, and provide recovery supports to people with addictionproblems has major adverse consequences in the state. It isone of the underlying causes of much of the social unrest weexperience including crimes, motor vehicle accidents anddeaths, child abuse and neglect, and family violence. We canno longer afford to stigmatize and ignore peoplewith addictionproblems. Thiswill require a paradigm shift away froman acutecaremodel that expects people to be “cured” after one courseof treatment and from the traditional view of addiction as amoral failing. Rather, North Carolina should begin to managedependence as any other chronic disease and provide ongoingcare and support to help people remain in recovery. Creatingthis newmodel of care—with strong investments in prevention,early intervention, treatment, and recovery supports—willrequire the active involvement of many different agencies,providers, and treatment professionals. Services need to beavailable and accessible throughout the state and provided bya qualified substance abuse workforce. With relatively smallinvestments, North Carolina can create an effective system ofcare that helps people reduce their relianceon tobacco, alcohol,and other drugs. NCMJ

Acknowledgements:

This Task Force was convened at the request of the NorthCarolina General Assembly and was funded by stateappropriations to the North Carolina Institute of Medicine.The Task Force would not have been possible without thegenerosity of Task Force and Steering Committee membersvolunteering their time. Co-chairs: Dewayne Book, MD,Fellowship Hall; Representative Verla Insko, NC House ofRepresentatives; Senator Martin L. Nesbitt Jr, JD, NC Senate.Task Force Members: Representative Martha Alexander, NCHouse of Representatives; Patrice Alexander, PhD, SPHR,Greenville Utilities; Robert H. Bilbro,MD, TheHealing Place of

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ur understanding of drug addiction balances uneasilyat the intersection of scientific and public knowledge.

Few issues mix morality, science, public policy, and simpleignorance in such a volatile way. Older but entrenched viewsof addiction cast it as a moral failure, the result of weaknessof will, or simply bad behavior.1 Points of view like theselogically led to the use of the criminal justice system as thesolution to the addiction problem. Now, however, realizing thisapproachhas failed, even lawenforcementpersonnelare lookingfor ways to keep nonviolent drug abusers and addicts out ofjail. In addition to failing to treat addiction, criminal justiceapproaches also reinforce the damaging stigma that surroundsaddiction and which actuallyimpairs a person’s ability toseek and obtain treatment.

Recent approaches haveemphasized psychologicalandsocial sciencehypothesesthat trace the cause ofaddiction to a response toparental abuse or neglect ortounhealthysocial conditionslike poverty or inner citydecay.2The solutions to theseproblems also seemed clear,though almost impossible toeffectively achieve. Mostrecently, however, intensiveneurobiological researchhas made an increasinglystrong case that whateverother factors may play a role in the etiology of addiction,addiction itself is a brain disease.3-5 Describing the evidencebehind that conclusion will be the focus of this commentary.

The neurobiological perspective posits that whatever theinitial cause of drug use or its escalation into abuse, addictiondevelops over time in response to repeated, high dose drugself-administration.6 Such long-term drug abuse engagespowerful conscious and unconscious learning mechanismswhile at the same time altering the chemistry andmicroanatomy of the brain.7,8 The resulting physical brainchanges manifest themselves in changes of behavior, themost obvious being the loss of control over drug taking.While

we have long known that addicts are compulsive drug userswho seek and use drugs even in the face of negative personal,social, and legal consequences, the brain changes thatunderlie this behavioral syndrome have only recently becomeapparent to scientists. As a result, there is a disconnectbetween what the community believes about addiction andwhat scientists have discovered.

Recent findings indicate that the brain changes causedby long-term drug use continue to manifest themselves wellinto abstinence and may be a cause of the relapses intocompulsive drug use that can occur long after the drug hasbeen cleared from the body. That relapses can occur long

after addicts have beendetoxified is evidence ofan enduring alteration ofthe brain, butmuch of thepublic has not yet cometo clearly understandhow the brain governsbehavior and doesn’treally understand whyaddicts can’t simplystop, especially afterthey become aware ofthe dangers and negativeconsequencesofdruguse.

Why is this important?Simply put, the more weallow our public policiesto be influenced by theknowledge that science

brings us, the more likely we are to develop policies that willbe effective. In 1973, the state of New York enacted the harshRockefeller drug laws, which included long, mandated prisonsentences for drugpossession anddistribution. The logic behindthese laws was that once people understood the devastatingconsequences of being caught with drugs, they would quicklyconclude that drug use just wasn’t worth it. Following NewYork’s lead, many other states have imposed similarly severepenalties on both drug users and drug dealers.

Looking back 35 years later, however, it has becomeapparent that incarceration represents theworst kind of policyoutcome: it is both ineffective and expensive. It has ruined far

Drug Addiction:A Chronically Relapsing Brain Disease

David P. Friedman, PhD

David P. Friedman, PhD, is a professor of physiology and the associate dean for research at the Wake Forest University School ofMedicine. He can be reached at dfriedmn (at) wfubmc.edu.

“… the more we allowour public policiesto be influenced by theknowledge that sciencebrings us, the more likelywe are to develop policiesthat will be effective.”

O


too many lives because of convictions for simple possession,and we have had to invest billions of dollars to build andmaintain prisons in part for those caught up in the extensivesentences required by these laws.Worse, prison by itself doesnothing to help or rehabilitate people addicted to drugs.Indeed, the relapse rate into drug abuse among thosereleased from prison without treatment and follow-up careapproaches 95%.9 Because it is clear that drug users beingreleased from prison understand that continued drug use willput them at risk for prison, it seems apparent that something isinterfering with their ability to act rationally on that knowledge.

Understanding the neural basis forwhy drugs can overcomegood judgment even in the face of harsh penalties has beenthe subject of intense scientific interest for only about 30 years,but we are now seeing an ever-increasing payoff from all thatwork. It is now clear that long-term use of addictive drugs,including alcohol and tobacco, alters the activity in and structureof a specific mesolimbic neural circuit commonly referred toas the “brain reward pathway.”4 This circuit, which comprisesthe neural substrate formotivation and reinforcement, includeslimbic structures like the amygdala and hippocampus, thedopamine-containing neurons of the ventral tegmental area(VTA), thenucleusaccumbens (NAS), and theprefrontal cortex,especially its orbital and medial portions (OMPFC). An acuteeffect that all addictive drugs share is to increase the releaseof dopamine from the terminals of VTA neurons into thenucleus accumbens and prefrontal cortex. This release ofdopamine is highly correlated with reward value.10

Long-term use of addictive drugs has profound effects onthis system. Chronic cocaine self-administration, for example,decreases the densities of dopamine receptors11,12 andincreases the density of dopamine transporters in the nucleusaccumbens.13 The decrease in the density of the D2 class ofdopamine receptors appears to be a universal response to thelong-term use of addictive drugs,14 and may outlast thepresence of the drug in the body by many months, if notyears.15Moreover, drugs alter themicroanatomy of neurons inthe nucleus accumbens and prefrontal cortex,16changing theway they respond to other neural signals, including thosehaving to do with learning and memory.

Another key region of recent interest is the OMPFC.17

Among other functions, it helps to determine the valence(want or avoid) of potential actions and rewards and theirhedonic value (strength of wanting). Drug craving induced inpatients who are undergoing positron emission tomography(PET) or functional magnetic resonance imaging (fMRI)scans show that the OMPFC is particularly activated duringdrug craving, and that the intensity of craving is proportionalto the metabolic activity in the OMPFC.10,18 Injury to theOMPFC in non-drug users causes deficits in a person’s abilityto select a large reward that will be available in the futurerather than a small one that is available immediately.19 Theinability to put off the short-term pleasure of immediate druguse in the face of knowledge that the future will be betterwithout drugs is one of the characteristic deficits of addiction,and recent evidence indicates that long-term drug addicts are

impaired in the same way brain-injured subjects are whentrying tomake this type of decision.MRI changes indicative ofinjury in the OMPFC have also been reported andmay underliethe behavioral deficit.20Thus, the very ability of people addictedto drugs to make sound decisions about drug use may beundermined by drug-induced damage to the brain regionsmost essential in making those decisions.

Commonchronic relapsingdiseases have a variety of thingsin common. For example, atherosclerosis, type 2 diabetes, andhypertension are all characterized by:

� No cure� Genetic risk factors� Based in voluntary behaviors� Cause biological changes in the body� Can be treated with medications� Require lifestyle changes for best control� Relapses and treatment failures are common (due to

failure to adhere to treatment regimen)

Atherosclerosis, for example, cannot be cured, but it canbe controlled. There are clear genetic risk factors, and poordiet, failure to manage stress, and failure to exercise are allcontributing factors. Arterial plaques are an eventual result,and while medications can reduce both the risk for andincidence of plaques, ultimate control requires changes indiet, exercise, and stressmanagement. Less than 60%of thosetreated for atherosclerosis adhere to their medication or dietand exercise changes, and 30%will require retreatment withinone year.

This is just like addiction. Most treatment experts agreethat there is no cure, per se, but it can be controlled. Geneticsaccount for 50-70%of the risk of addiction and, once addicted,people experience clear structural and functional changes intheir brains. Medications, like methadone for heroin addictionornaltrexone for either heroinor alcohol addiction, can increasethe probability of treatment success, but eventual controlrequires changes in lifestyle, the most important being thecessationof druguse. Relapses intodruguse are a characteristicof recovery for many people.

All of these points hold true for type 2 diabetes andhypertension as well, so when we look at these keycharacteristics, addiction is nearly indistinguishable fromother chronic diseases. A huge difference, however, occursduring treatment. Whereas failure of treatment of any of theclassic diseases results in a switch to other treatment regimensor an increase in intensity of treatment, peoplewith addictionswho fail to progress or who relapse are often thrown out oftreatment. Health insurance will cover multiple episodes oftreatment for atherosclerosis, even treatment for multipleheart attacks, but insurance companies impose such restrictivelimitations on treatment for addiction as to almost assure itwill fail for most of the people who need it.21

The way treatment for addiction is delivered and paid forin our society reflects a failure of new scientific information toalter entrenched biases against people with addictions. Even


though their behavior is quite analogous to that of peoplewithother chronic diseases that are brought on at least in part bylifestyle choices, people with addictions are stigmatizedbecause a drug is involved. Because people generally don’tunderstand how the brain controls behavior and how drugschange the brain, we shortchange treatment but pay for thatmany times over in downstream costs for broken families,

crime, incarceration, and addiction-related diseases. We canonly hope that a clearer understanding of the neurobiology ofaddiction and the other scientific findings about the costeffectiveness of prevention and treatment will lead to policy-making that is clear-headed and cost effective, with a focuson funding effective drug abuse prevention and addictiontreatment. NCMJ

REFERENCES

1 Morse SJ. Medicine and morals, craving and compulsion. SubUse Misuse. 2004;39(3):437-460.

2 Maggs JL, Patrick ME, Feinstein L. Childhood and adolescentpredictors of alcohol use and problems in adolescence andadulthood in the National Child Development Study. Addiction.2008;103(suppl 1):7-22.

3 Leshner AI. Addiction is a brain disease, and it matters. Science.1997;278(5335):45-47.

4 Wise RA. Addiction becomes a brain disease. Neuron.2000;26(1):27-33.

5 Volkow ND, Li TK. Drug addiction: the neurobiology of behaviourgone awry. Nat Rev Neurosci. 2004;5(12):963-970.

6 Koob GF, Le Moal M. Drug addiction, dysregulation of reward,and allostasis. Neuropsychopharmacology. 2001;24(2):97-129.

7 Hyman SE, Malenka RC, Nestler EJ. Neural mechanisms ofaddiction: the role of reward-related learning and memory.Annu Rev Neurosci. 2006;29:565-598.

8 Robbins TW, Ersche KD, Everitt BJ. Drug addiction and thememory systems of the brain. Ann NY Acad Sci. 2008;1141:1-21.

9 Hiller ML, Knight K, Simpson DD. Prison-based substanceabuse treatment, residential aftercare and recidivism. Addiction.1999;94(6):833-842.

10 Schott BH, Minuzzi L, Krebs RM, et al. Mesolimbic functionalmagnetic resonance imaging activations during reward anticipationcorrelate with reward-related ventral striatal dopamine release.J Neurosci. 2008;28(52):14311-14319.

11 Moore RJ, Vinsant SL, Nader MA, Porrino LJ, Friedman DP.Effect of cocaine self-administration on striatal D1 dopaminereceptors in rhesus monkeys. Synapse. 1998;28(1):1-9.

12 Moore RJ, Vinsant SL, Nader MA, Porrino LJ, Friedman DP.Effect of cocaine self-administration on dopamine D2 receptorsin rhesus monkeys. Synapse. 1998;30(1):88-96.

13 Letchworth SL, Nader MA, Smith HR, Friedman DP, Porrino LJ.Progression of changes in dopamine transporter binding sitedensity as a result of cocaine self administration in rhesusmonkeys. J Neurosci. 2001;21(8):2799 2807.

14 Volkow ND, Fowler JS, Wang GJ, Swanson JM, Telang F.Dopamine in drug abuse and addiction: results of imagingstudies and treatment implications. Arch Neurol.2007;64(11):1575-1579.

15 Nader MA, Morgan D, Gage HD, Nader SH. PET imaging ofdopamine D2 receptors during chronic cocaine self-administrationin monkeys. Nat Neurosci. 2006;9(8):1050-1056.

16 RobinsonTE, GornyG,Mitton E, Kolb B. Cocaine self-administrationalters the morphology of dendrites and dendritic spines in thenucleus accumbens and neocortex. Synapse. 2001;39(3):257-266.

17 Everitt BJ, Hutcheson DM, Ersche KD, Pelloux Y, Dalley JW,Robbins TW. The orbital prefrontal cortex and drug addiction inlaboratory animals and humans. Ann NY Acad Sci.2007;1121:576-597.

18 Goldstein RZ, Volkow ND. Drug addiction and its underlyingneurobiological basis: neuroimaging evidence for the involvementof the frontal cortex. Am J Psychiatry. 2002;159(10):1642-1652.

19 Clark A, Bechara H, Damasio H, Aitken MR, Sahakian BJ,Robbins TW. Differential effects of insular and ventromedialprefrontal cortex lesions on risky decision-making. Brain.2008;131(pt 5):1311-1322.

20 Makris N, Gasic GP, Kennedy DN, et al. Cortical thicknessabnormalities in cocaine addiction—a reflection of both druguse and a pre-existing disposition to drug abuse? Neuron.2008;60(1):174-188.

21 McLellan AT, McKay JR, Forman R, Cacciola J, Kemp J.Reconsidering the evaluation of addiction treatment: fromretrospective follow-up to concurrent recovery monitoring.Addiction. 2005;100(4):447-458.


pproximately 3 out of 10 US adults drink at levels thatelevate their immediate and long-term risk for physical,

mental, and social problems.1 Few seek treatment from thespecialty substance abuse (SA) treatment system that hastraditionally targeted the very small percentage of alcohol-dependent patients (less than 5%) and does not address theneeds of the20%or sowhoare exceeding recommended limits.a

These groups put themselves and others at risk of injury andincrease their likelihood of developing alcohol dependence,chronicdiseases, neurological impairments, andsocial problems(see Figure 1).2

In communities across North Carolina and the country,patients with SA issues are regularly presenting at localemergency departments (EDs) and the ED, in many instances,has become a default SA provider for the community. Clearly,patients are not receiving adequate identification, treatment,or support for their substance use disorders elsewhere in thecommunity and, as a result, crises frequently bring them tothe ED. This is not a good use of resources nor is it the meansto providing high quality care.

If identified early and treated appropriately, substance usedisorders can be successfully managed in the primary caresetting without further progression. Because at-risk drinkerscommonly present to primary care settings, practitioners atthese sites can have significant impact in reducing the harmassociated with at-risk drinking and can often motivatedependent individuals to seek treatment. This provides anopportunity for substance abuse identification and interventionthat has yet to be optimally leveraged.

Integrated Physical and BehavioralHealth Care

A number of health-related social and financial factors(including dissatisfaction with the carve-out modelb) haveresulted in a large-scale move to integrate physical health(PH) and behavioral health (BH), includingmental health and

substance use, a model known as integrated care. There aredifferent levels and definitions in integrated care with varyingdimensions and degree of integration; however a recentAHRQ study was unable to identify an optimal integrationmodel as a number of different models were shown to beeffective.3 In otherwords, integrated care iswidely consideredthe best way to ensure access to BHwhen it is needed, reducingthe relative risk and the risk of progression tomore hazardousand/or dependent use.

Integrated care is a means for intervening earlier, reducingprogression tomore intensive disease, and obviating the needformore intensive treatment, thus reserving specialty BH carefor those withmore serious disorders. Integrated care reducesstigma and increases engagement in treatment.4 In addition,approximately 70%of all primary care visits have psychosocialdrivers, and the burden of BH markedly complicates theprocess and cost.5Thus, integrated care also leads to improvedoutcomes at a reduced cost.4 Furthermore, integration is moreperson-centered and approaches depression and substance

a Maximum drinking limits are as follows: no more than 4 drinks in one day and no more than 14 drinks in one week for men and no morethan 3 drinks in one day and no more than 7 drinks in one week for women.1

b The carve-out model is a managed care term for a program that separates mental health and substance abuse services from the mainstreammedical system and provides them separately.

“If identified early andtreated appropriately,substance use disorderscan be successfully

managed in the primarycare setting withoutfurther progression.”

Sara McEwen, MD, MPH, is the executive director of the Governor’s Institute on Alcohol and Substance Abuse. She can be reachedat sara.mcewen (at) governorsinstitute.org.

Substance Abuse Screening and BriefIntervention in Primary CareSara McEwen, MD, MPH


A


abuse (and certain other BH conditions) as the chronicrelapsing conditions that they are.

The movement toward integrated care is occurring locally,nationally, and internationally. In the groundbreaking Crossingthe Quality Chasm: A New Health System for the 21st Century,the Institute of Medicine of the National Academies statesthat, “It is not possible to deliver safe or adequate healthcarewithout simultaneous consideration of general health, mentalhealth, and substance abuse issues.”6 The Four QuadrantModel depicts the intersection between BH and PH and therecommended treatment setting (see Figure 2).7Quadrant onerepresents the large number of patients with nondependent,at-risk substance abuse and/ormild tomoderatemental illnesswho can be successfully treated in the primary care setting.

Substance Abuse Screening, Brief Intervention,and Referral to Treatment (SBIRT)

There is good evidence that counseling by a physiciandoes have an effect on subsequent drinking behavior.3 SBIRTis a well-studied, cost-effective approach to integration ofsubstance abuse identification, intervention, and primaryhealth care.8,9 Brief interventions (BIs) have been shown to beeffective with smokers and drinkers. SBIRT for illicit drugs andprescription drugs is less well-studied, but there is an increasingevidencebase that suggests SBIRT is effective for thesedisordersas well. SBIRT has been shown effective with both gendersand diverse socioeconomic and ethnic populations.10-12

SBIRT interventions target two groups: those who meetcriteria for dependence and need specialty treatment andthose engaging in moderate or high risk substance use butwho do not meet criteria for dependence. We now have over

two decades of clinical research andprogram development, consensusfrom medical specialty groups, andeffective screening, BI protocols, andtraining available.

Components of SBIRTScreening

Screening identifies patientswhosedrinking puts them and others at riskand identifies patients who are likelydependent.Thereareseveralvalidatedscreening tools including AUDIT,ASSIST,MAST, CAGE-AID, DAST foradults, and CRAFFT for adolescents.

Brief InterventionConducting a brief intervention

can help motivate behavior changeby aiding the patient to see theconnectionbetweenhisorherdrinkingand his or her health problem. This isa “teachablemoment.”BIsare low-costand time-limited (5-15 minutes in

duration). BIs using motivational approaches are effective interms of clinical effectiveness and cost.8 The goals of BI are toreduce consumption and alcohol-related problems and/orfacilitate treatment engagement bymotivatingpatient tomakea decision about decreasing his or her risky use. Specifically, aFRAMES approach is recommended: Feedback, Responsibility,Advice, Menu of strategies, Empathy, and Self-efficacy. BIscan also be useful in getting dependent patients to enterspecialized substance abuse treatment.

Referral to TreatmentPatients who are likely dependent should be referred for

further assessment and/or specialized treatment.

Follow-UpPatient outcomes improve when follow-up is provided.

This can be a phone call reinforcing the brief intervention, areferral to the patient’s primary care physician, or attendanceat a 12-step program in the community. After a formalsubstanceabuse treatment episode, thepatient is referredbackto the primary care setting for follow-up care. Bi-directionalcommunication and linkagesbetweenprimary care and specialtySA care are important. Additionally, community peers whoare in recovery can be a great asset in helping the patient getconnected with resources in the community such as specialtySA treatment and self-help groups.

Outcomes Associated with SBIRT

SBIRT has been shown to decrease the frequency andseverity of drug and alcohol use, reduce the risk of trauma,and increase the percentage of patientswho enter specialized

Figure 1.The Drinker’s Pyramid

Source: Babor T, Higgins-Biddle JC. Brief Intervention for Hazardous and Harmful Drinking: AManual for Use in Primary Care. Geneva, Switzerland: World Health Organization; 2001.

substance abuse treatment. It is also associated with fewerhospital days and fewer emergency department visits. Cost-benefit and cost-effectiveness analyses have demonstratednet cost savings for this approach.8-11

The decreased ED and hospital usage payoff is estimatedconservatively at 4:1; for every $1 used for SBIRT, there is asavings of at least $4 in reduced ED and hospital use.13 Otherestimates of cost effectives range from 4:1 to 7:1. Additionalcost savings accrue due to the decreased costs to society (e.g.criminal justice).

Barriers to SBIRT

Despite strong support for SBIRT, a number of barriersstand in the way of widespread implementation. Our presenthealth care system is largely focused on acute care; thetransition to a more population-based care management/preventive system doesn’t occur quickly. In addition, medicalschool and residency training about substance abuse is fairlycursory, and many physicians do not feel comfortableintervening. Many physicians are not knowledgeable aboutthe chronic disease nature of substance abuse nor are theyaware that treatment for SA is as effective as treatment forother chronic conditions such as asthma, diabetes, andhypertension (see Table 1).14,15 Office systems (flow as well asbilling) generally do not incentivize SA identification andintervention. Financial barriers are a major impediment,primarily because critical functions of integrated care (e.g.care management, consultation, and communication betweenproviders) are not reimbursed by traditional fee-for-service.3

Other financial, organizational, and administrative barriersalso stand in the way.

Because of these obstacles, successful SBIRT implementationrequires the following elements: (1) initial and ongoing trainingfor clinical and administrative staff; (2) realignment of fundingand reimbursement mechanisms with technical assistance for

troubleshooting problems; and (3) incorporation into a largerhealthpolicy and legislative framework supportedby leadership,adequate resources, and coordination of a network of servicesat different levels of care.4

Support for Integrated Care and SBIRT

There is general agreement that substance abuse is bestunderstood and treated as a chronic, relapsing condition, andthat there is a need to broaden the base of treatment to expand

treatment and early interventionservices. Screening and briefintervention in the primary careand emergency settings havebeen endorsed and recommendedby all major primary care specialtyand public health groups. Thesegroups include the AmericanMedical Association, AmericanAcademy of Family Physicians,American Academy of Pediatrics,American College of Physicians,American PsychiatricAssociation,American College of EmergencyPhysicians, American College ofSurgeons Committee on Trauma,AmericanCollege ofObstetriciansand Gynecologists, and theAmerican Society of AddictionMedicine. Integrated care andSBIRT have international backing

as well, with an endorsement from the World HealthOrganization.4

Integrating behavioral health and traditional physicalhealth is an increasingly important priority at the federal level.The President’s New Freedom Commission on Mental Healthreport has called for primary care screening for mental illnessand co-occurringmental illness and substance use disorders.16

The priority on integrated care is also evidenced by the numberof large grants which include SBIRT and other behavioralhealth/primary health (BH/PH) integration efforts and thefederal resources devoted to SBIRT by agencies such as theSubstanceAbuse andMental Health ServicesAdministration,the National Institute on Alcohol Abuse and Alcoholism, theNational Institute on Drug Abuse, and the Health Resourcesand Services Administration’s Bureau of Primary Care.

The federal government has also shown leadership in SBIRTfinancing and sustainability, establishing reimbursementcodes for screening and brief intervention for both MedicaidandMedicare patients. Some private insurers have also startedto reimburse for these services. These codes do not solve thereimbursement problem but they are a good start. GeorgeWashingtonUniversity’s EnsuringSolutions toAlcohol Problemsproject addresses themany financial andorganizational barriersand is an invaluable resource for those wishing to adopt theseapproaches (see http://www.ensuringsolutions.org).

Figure 2.The Four Quadrant Clinical Integration Model

Source: Mauer B. Behavioral Health/Primary Care Integration: The Four Quadrant Model and Evidence-Based Practice. The National Council for Community Behavioral Healthcare website.http://www.thenationalcouncil.org. Accessed February 11, 2009.


The American College of Surgeons Committee on Traumahas also shown leadership bymandating in 2007 that all level Itrauma centers be required to provide SBIRT services. In fact, itis traumasurgeonswhoareat the forefront of SBIRTpromotion,leading with initiatives and research that demonstrates theimportance of identifying patients with at-risk and dependentsubstance use and intervening appropriately with thesepatients. Brief interventions conducted in trauma centers havebeen shown to reduce trauma recidivism by asmuch as 50%.17

In addition, screening in this setting allows for identification ofat-risk use, which can often bemodulated by brief intervention.It also allows for identification of dependent patients whoneed a more comprehensive assessment and/or specialty SAtreatment.

Experience indicates that once introduced as standardpractice into an emergency department, SBIRT often spreadsthroughout the hospital as its utility and value are recognizedby physicians, nurses, and administrators. Washington Stateserves as one example. Until exposed to these interventionsand initiatives, physicians are often unaware that SBIRT can beintegrated into a busy practice and can facilitate managementof other chronic diseases.18

SBIRT Efforts Underway in North Carolina

A number of SBIRT pilots and initiatives are underway inhospitals, emergency departments, and primary care settingsacross North Carolina. These include federally-funded,

state-funded, and foundation-funded SBIRT grant projects aswell as those funded by hospitals and physician practices.North Carolina’s Area Health Education Centers Program(AHEC) and the ICARE partnership provide statewide trainingand technical assistance. The ICARE partnership is providingpractice-based technical assistance around reimbursementand is currently running two pilot SBIRT projects with plansfor additional pilots in the eastern part of the state (seehttp://www.icarenc.org). The ICARE partnership has led tovastly increased collaboration and visibility of integrated careefforts in the state.

In addition, the North Carolina General Assembly hasprovided nonrecurring funds that allowed Community Care ofNorth Carolina (CCNC) to pilot stronger integration ofmentalhealth services into the primary care setting. In addition topromoting evidenced-based screening and brief interventions,CCNC applies its population-based chronic disease caremodel to mental illnesses such as depression. Evaluation willinclude clinical, functional, and financial outcomes. WhileICARE has assumed the coordinating role around mentalhealth and primary care integration, the Governor’s Instituteserves as a coordinator of SBIRT projects, initiatives, andtraining in the state (see http://www.governorsinstitute.org).

Our health care system does a poor job of identifying andintervening with alcohol and drug users who are exceedingrecommended limits but who have not yet developeddependence. Similarly, specialty SA treatment has long beentailored to chronic, relapsing alcoholics. Much of the 25% of

Table 1.Comparisons Among Alcohol-Related Problems and Other Chronic Diseases

Alcohol-Related Asthma Diabetes High BloodProblems Pressure

Prevalence 13.8 million 17.6 million 10 million 50 millionTotal economic costs $185 billion $111 billion $98.1 billion $40 billionHealth care costs $26.3 billion $7.5 billion $44.1 billion $29 billionOther medical complications Yes No Yes YesCausesControllable risk factors Yes Yes Yes YesUncontrollable risk factors Yes Yes Yes YesEstimated genetic influence 50-60% 36-70% 30-55% - type I 15-50%

80% - type IITreatmentCure No No No NoResearch-based treatment Yes Yes Yes YesguidelinesEffective patient/family education Yes Yes Yes YesPercentage of patients who follow 40-60% 30% 30% 30%treatment regimens faithfullyPercentage of patients whorelapse within one year 40-60% 50-70% 30-5-% 50-70%Source: Adapted from: The GeorgeWashington University Medical Center. Costs and Benefits. Ensuring Solutions to Alcohol Problemswebsite. http://www.ensuringsolutions.org/resources. Accessed February 11, 2009.


the population who exceed drinking limits with or withoutdependence are more appropriately treated in the primarycare setting.Many of these patients will benefit from one ormore brief interventions that take place in the primary caresetting. If identified early and treated appropriately, substanceuse disorders can be successfully managed without furtherprogression. The limited resources of the specialty substanceabuse treatment system can then be used in a manner thatis more appropriate and cost-effective for patients requiringmore intensive intervention. NCMJ


REFERENCES

1 National Institute on Alcohol Abuse and Alcoholism. HelpingPatients Who Drink Too Much: A Clinician’s Guide. Bethesda, MD:National Institutes of Health; 2005.

2 Alcohol quick stats: general information on alcohol use andhealth. Centers for Disease Control and Prevention website.http://www.cdc.gov/alcohol/quickstats. Accessed November17, 2008.

3 Butler M, Kane RL, McAlpine D, et al. Integration of MentalHealth/Substance Abuse and Primary Care. Rockville, MD:Agency for Healthcare Research and Quality; 2008. AHRQPublication No. 09-E003.

4 World Health Organization.World Health Organization andWorld Organization of Family Doctors’ Integrating Mental Healthinto Primary Care: A Global Perspective. Geneva, Switzerland:World Health Organization; 2008.

5 Strosahl K. Integrating primary care and behavioral healthservices: a compass and a horizon. A curriculum for communityhealth centers. www.apa.org/rural/strosahl.pdf. AccessedFebruary 5, 2009.

6 Institute of Medicine of the National Academies. Crossing theQuality Chasm: A New Health System for the 21st Century.Washington, DC: National Academies Press. 2001.

7 Mauer B. Behavioral Health/Primary Care Integration: The FourQuadrant Model and Evidence-Based Practices. Rockville, MD:National Council for Community Behavioral Healthcare; 2004.

8 Babor TF, Kadden RM. Screening and intervention for alcoholand drug problems in medical settings: what works? J Trauma.2005;59(3 suppl):80-87.

9 Fleming MF, Mundt MP, French MT, Manwell LB, StauffacherEA, Barry KL. Brief physician advice for problem drinkers:long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res.2002;26(1):36-43.

10 Babor T, McRee B, Kassebaum P, Grimaldi P, Ahmed K, Bray J.Screening, brief intervention, and referral to treatment (SBIRT):toward a public health approach to the management ofsubstance abuse. Subst Abus. 2007;28(3):7-30.

11 Sullivan E, Fleming M. A Guide to Substance Abuse Services forPrimary Care Physicians. Treatment Improvement Protocol 24 (TIP24). Rockville, MD: Dept of Health and Human Services; 1997.

12 Miller WR. Enhancing Motivation for Change in Substance AbuseTreatment. Treatment Improvement Protocol 35 (TIP 35).Rockville, MD: Dept of Health and Human Services; 1999.

13 Fleming M. SBIRT. Presented to: Addiction Recovery Institute’sCarolinas Conference; October 31, 2008; Chapel Hill, NC.

14 The GeorgeWashington UniversityMedical Center. Comparisonsamong alcohol-related problems including alcoholism andother chronic diseases. http://www.ensuringsolutions.org/usr_doc/Chronic_Disease_Comparison_Chart.pdf. AccessedNovember 10, 2008.

15 National Institute on Drug Abuse. Principles of Drug Addiction: AResearch Based Guide. Bethesda, MD: National Institute ofHealth; 1999. Publication No. 99-4180.

16 The President’s New Freedom Commission on Mental Health.Achieving the Promise: Transforming Mental Health Care inAmerica. Rockville, MD: US Dept of Health and HumanServices; 2003. Publication No. SMA-03-3832.

17 Gentilello LM, Rivara FP, Donovan DM, et al. Alcohol interven-tions in a trauma center as a means of reducing the risk ofinjury recurrent. Ann Surg. 1999;230(4):73-480.

18 PRISM systematic commissioned reviews: presentations andpublications. Treatment Research Institute website.www.tresearch.org/add_health/prism_resources.htm.Accessed November 18, 2008.

Table 2.Recommended SBIRT Resources

SAMHSA/CSAThttp://www.sbirt.samhsa.govNIAAAhttp://www.niaaa.nih.gov/Publications/EducationTrainingMaterialsEnsuring Solutions to Alcohol Problemshttp://www.ensuringsolutions.orgICARE Partnershiphttp://www.icarenc.orgAmerican College of Surgeonshttp://www.facs.org/trauma/publications/sbirtguide.pdf


Recovery-oriented systems of care shift the question from, “Howdo we get the client into treatment?” to “How do we support theprocess of recovery within the person’s environment?”1

—H.Westley Clark, MD, JD, CAS, FASM

hepastdecadehasbeenmarkedbyagrowing involvementof consumers in the management of their own health

care. Individuals, in collaboration with their caregivers, haveassumed responsibility forwellnessmanagement for a varietyof conditions.

Over the past several years, a variety of groups haveattempted to define recovery from drug and alcohol addictionwith comparable results. In 2005, the Substance Abuse andMental Health Services Administration’s Center forSubstance Abuse Treatment (SAMHSA/CSAT) held aNational Summit on Recovery which convened over 100individuals representing the treatment and recovery field.While it was acknowledged that individuals may chose todefine recovery differently, a working definition of recovery,reflecting the tenor of the Summit deliberations, emerged:Recovery from alcohol and drug problems is a process of changethrough which an individual achieves abstinence and improvedhealth, wellness, and quality of life.2

The addictions treatment field across the nation isundergoing a fundamental shift in the way we view thedisease of addiction to drugs and alcohol and, consequently,a shift in the way we deliver services to those in need. Fordecades, an acute care model has been used to deliverepisodic treatment to people when their symptoms are mostsevere. Clinical experience and studies conducted over severaldecades confirm that while someindividuals can sustain long-termrecovery through acute care treatment,over one-half of the clients enteringpublicly-funded treatment programsrequire many episodes of treatmentover a period of several years toachieve and sustain recovery.3,4 Inaddition, people have been assigned toavailable models of treatment withoutregard to their individual requirementsor unique life circumstances.

The concept of recovery-oriented systems of care forpeople suffering from addiction to drugs and alcohol is notnew to the addictions treatment field. However, the terminologyhas surfaced in recent years as a way of capturing the shift inpractice from treating addiction as an acute, episodic diseaseto acknowledging the chronic, relapsing nature of the illnessand the need for person-centered services over the continuumof the recovery process.

The participants in the SAMHSA/CSATSummit,more thanone-half of whom are in recovery from addiction, providedgeneral direction to SAMHSA and other stakeholder groupsto assist in developing and implementing recovery-orientedsystems of care in the form of guiding principles and systemsof care elements.

The guiding principles of recovery from addiction are:2

� There are many pathways to recovery.� Recovery is self-directed and empowering.� Recovery involves a personal recognition of the need

for change and transformation.� Recovery is holistic.� Recovery has cultural dimensions.� Recovery exists on a continuum of improved health and

wellness.� Recovery emerges from hope and gratitude.� Recovery involves a process of healing and self-

redefinition.� Recovery involves addressing discrimination and

transcending shame and stigma.� Recovery is supported by peers and allies.

Recovery-Oriented Systems of Care, theCulture of Recovery, and Recovery SupportServicesDonna M. Cotter, MBA

DonnaM. Cotter,MBA, is a private consultant in the area of substance abuse treatment. She can be reached at dcotter (at) nc.rr.com.

“For many, the recovery processis marked by cycles of treatment,recovery, relapse, and repeatedtreatment before resulting inlong-term stable recovery.”

T

� Recovery involves (re)joining and (re)building a life inthe community.

� Recovery is a reality.

Further, a recovery-oriented delivery system should containthe following system of care elements:2

� Person-centered� Family and other ally involvement� Individualized and comprehensive services across the

lifespan� Systems anchored in the community� Continuity of care� Partnership-consultant relationships� Strengths-based� Culturally responsive� Responsiveness to personal belief systems� Commitment to peer recovery support services� Inclusion of the voices and experiences of recovering

individuals and their families� Integrated services� System-wide education and training� Ongoing monitoring and outreach� Outcomes driven� Research-based� Adequately and flexibly financed

Across the country, states such as Connecticut, Arizona,and Michigan and the city of Philadelphia have over timesuccessfully transformed their addiction treatment deliverysystems into recovery-oriented systems of care. Theirwell-documented experiences of lessons learned along thepath to transformation, serve as examples from which otherstates can benefit.5-7

During a SAMHSA-sponsored training session to assiststates inplanningand implementing recovery-orientedsystemsof care held in Charleston, South Carolina in January of 2008,the team of representatives from North Carolina concurredwith and committed to using both the principles and systemsof care elements developed at the 2005 National Summit onRecovery in the design of North Carolina’s recovery-orientedsystems of care.

Teammembers recognized the need to create a conceptualplan for the state, aswell as review andmodify planning relatedto funding. They further acknowledged the need to developcurricula to educate groups such as consumers, providers,funders, and policymakers. The team also stated the need tocollaborate and get buy-in across systems such as housing,justice, employment, social services, and mental health, aswell as to provide ongoing training to Local ManagementEntities, consumers, and the provider workforce.Steps that North Carolina has already taken to implementrecovery-oriented systems of care include:

� A state Substance Abuse Treatment ImprovementTeam has been activated in the Division of MentalHealth, Developmental Disabilities, and SubstanceAbuse Services.

� A RecoveryNC campaign has been launched to reducethe stigma attached to persons in recovery andempower them to have a voice in matters that affecttheir recovery and the services they need.

� A Recovery Standing Committee is in place with thefollowing vision and mission: Vision: North Carolinianswill understand the value of recovery from drug andalcohol addiction and its significance to the well-beingof our communities.Mission: To educate and advocatefor recovery from drug and alcohol addiction in NorthCarolina.

� An Advocacy and Customer Service Section is in placewithin the North Carolina Department of Health andHuman Services with a direct line of report to theSecretary.

� State and local Consumer and Family AdvisoryCouncils have been established.

� A relationship has been established with the stateleadership of Alcoholics Anonymous and NarcoticsAnonymous, as well as an agreement to cooperate inthe implementation of recovery-oriented systems ofcare.

� Training has been offered across the state regarding thelegal rights and responsibilities of persons in treatmentfor and recovery from addiction.

� Initial surveys have been conducted and existingprovider workforce and system components have beenidentified.

The Culture of Recovery

The pathways to recovery are as numerous and unique asthe persons who travel them. Faces and Voices of Recovery, anational organization founded in 2001 to assist communitiesof people in recovery to advocate for their own needs, hasprepared a document entitled Pathways to Recovery, whichdescribes in detail the paths of treatment and sustainedrecovery available to people with addictions.8

For many, the recovery process is marked by cycles oftreatment, recovery, relapse, and repeated treatment beforeresulting in long-term stable recovery.9 Acknowledging thisprocess, many people working through their own recovery feelthe need to stay in touch with the recovery process as either acounselor or volunteer as away of ensuring or protecting theirrecovery. In addition, remaining faithful to the traditions thatbroughtmany to recovery requires them to reach back and helpothers on their own paths to recovery. As a result, many peoplein recovery join the ranks of clinicians delivering treatment topeople with addictions or become peer support specialistsproviding a variety of recovery support services.

Mutual aid or peer support groups have been shown toplay a significant role in the process of recovery.10-12 In factthere is a 250-year tradition of persons with drug and alcoholproblems banding together for mutual support in recovery.5

The most widely known peer support groups are the 12-steporganizations Alcoholics Anonymous (AA) and Narcotics


Anonymous (NA). In North Carolina, most recovery supportservices are obtained through these organizations. They areself-run, self-sustaining, free from outside intervention, andreceive no funding from outside sources.

There are also 129 Oxford House recovery homes in NorthCarolina with an average of nine residents per house (formore information on the Oxford House program, see thecommentary by Kathleen Gibson in this issue). They, too, areself-managed and funded. Studies have shown that thesupport, guidance, and shared information that Oxford Houseresidents obtain from fellow housemates help to enhancerecovery and reduce relapse.13

Recovery Support Services

Recoverysupport servicesdeliveredwithin recovery-orientedsystems of care are nonclinical serviceswhichmay be providedto individuals not requiring or seeking treatment. Theymayalsobe provided during and after treatment. They may include:

� Transitional housing or recovery homes, such asOxfordHousing

� Transportation� Life skills, parenting, employment, or vocational training

and support

� Food, clothing, or other basic needs� Child care� Family and/or spiritual support� Legal services� Recreation� Service brokerage� Recovery coaching, mentoring, and checkups

There is not an exact count of treatment providers withinNorth Carolinawho also offer comprehensive recovery supportservices for their clients. Notable among those who do areFirst Step ofWesternNorth Carolina, with locations in RaleighandGarner; TROSA inDurham; and First at Blue Ridge, Inc., inRidgecrest. Efforts are also being made at the University ofNorth Carolina to define roles for peer support specialists,and to prepare training materials to assist persons wanting todeliver these services to obtain certification to do so.

More work is necessary to prepare clear definitions andfundingmechanisms for thedeliveryofall of the recoverysupportservicesmentioned above. As previously noted, North Carolinahas already made initial steps and has put key committees inplacetobeginthetransitiontoacomprehensive, recovery-orientedapproach to the delivery of services for its residents who sufferfrom drug and alcohol addictions.NCMJ

REFERENCES

1 Clark HW. Lecture presented at: The Recovery Symposium;May 2008; Philadelphia, PA.

2 Summit on Recovery: Conference Report. Rockville, MD:Substance Abuse and Mental Health Services Administration;2007. Department of Health and Human Services PublicationNo. (SMA) 07-4276.

3 Dennis ML, Scott CK, Funk RK Foss MA. The duration andcorrelates of addiction and treatment careers. J Subst AbuseTreat. 2005;28(suppl 1):51-62.

4 Dennis ML, Foss MA, Scott CK. An 8-year perspective on therelationship between the duration of abstinence and otheraspects of recovery. Eval Rev. 2007;31(6):585-612.

5 Connecticut Department of Mental Health and AddictionServices. Practice guidelines for behavioral health care.www.ct.gov/dmhas/lib/dmhas/publications/practiceguidelines.pdf. Published 2006. Accessed January 8, 2009.

6 Michigan Department of Community Health. ODCP policy andtechnical advisory manual. http://www.michigan.gov/mdch.Accessed January 8, 2009.

7 Varieties of the recovery experience. Philadelphia Departmentof Behavioral Health/Mental Retardation Services website.http://www.phila.gov/dbhmrs/strategicplan. Accessed January8, 2009.

8 Recovery Advocacy Toolkit. Faces and Voices of Recoverywebsite. www.facesandvoicesorrecovery.org. AccessedNovember 15, 2008.

9 Anglin MD, Hser YI, Grella CE, Longshore D, Prendergast ML.Drug treatment careers: conceptual overview and clinical,research, and policy applications. In: Tims F, Leukefeld C, PlattJ, eds. Relapse and Recovery in Addictions. New Haven, CT: YaleUniversity Press; 2001:18-39.

10 Fiorentine R. After drug treatment: are 12-step programseffective in maintaining abstinence? Am J Drug Alcohol Abuse.1999;25(1):93-116.

11 McKay JR, McClellan AT, Alterman AI, Cacciola JS, RutherfordMJ, O’Brien CP. Predictors of participation in aftercare sessionsand self-help groups following completion of intensive outpatienttreatment for substance abuse. J Stud Alcohol. 1998;59(2):152-162.

12 Jason LA, Davis MI, Ferrari JR. The need for substance abuseafter-care: longitudinal analysis of Oxford House. Addict Behav.2007;32(4):803-818.

13 Jason LA, Davis MI, Ferrari JR, Bishop PD. Oxford House: areview of research and implications for substance abuse recoveryand community research. J Drug Educ. 2001;31(1):1-27.


roblems with accessing health care in both the publicand private sectors has been documented in the United

States and in North Carolina for a number of years. Substanceabuse disorders afflict approximately 13 million individualsnationally. Of those 13 million individuals only about 3 millionare receiving treatment, leaving approximately 10 millionpeople stranded in the “treatment gap.”1

The data for the public Mental Health,Developmental Disabilities, and SubstanceAbuse System in North Carolina showsa similar pattern; approximately 8% ofthose who needed treatment in SFY2007-2008 received it; 546,796 adultsand 53,144 children were in need oftreatment with 45,224 adults and 3,689children receiving treatment servicesrespectively.

In 1998, theUS SubstanceAbuse andMental Health Services Administrationtasked theNational Center for SubstanceAbuse Treatment to begin a nationaltreatment plan initiative. The goal wasto reach a working consensus on animprovement process for the addictionstreatment system in the United States.Panels from across the nation wereconvened and agreed on a final visionstatement:1

We envision a society in which people with a history ofalcohol or drugproblems, people in recovery, andpeopleat risk for these problems are valued and treated withdignity and where stigma, accompanying attitudes,discrimination, and other barriers to recovery areeliminated. We envision a society in which substanceabuse/dependence is recognized as a public healthissue, a treatable illness for which individuals deservetreatment. We envision a society in which high-qualityservices for alcohol and other drug problems are widelyavailable and where treatment is recognized as aspecialized field of expertise.

In 2007, the North Carolina Institute of Medicine(NCIOM) began an investigation of the barriers to accessingcare for those individuals and families seeking services forsubstance abuse problems. This vision statement reflects thecommitment of leaders from across the state to conduct aninventory of system issues and to identify ways to close the

treatment gap in the state. There are many reasons whyindividuals fail to get treatment, including stigma associatedwith the disorder, cost of treatment, unavailability of support,and failure of systems to effectively identify individuals anddirect them into treatment. The NCIOM Task Force onSubstance Abuse Services made recommendations that mayresult in a new, more effective system of prevention,treatment, and recovery in North Carolina. Many of theserecommendations are presented in this issue of the Journal,starting on page 27.

Making the Public Mental Health,Developmental Disabilities, and SubstanceAbuse System More Accessible:An Invitation to Recovery

Flo Stein, MPH

Flo Stein, MPH, is chief of the Community Policy Management Section in the Division of Mental Health, Developmental Disabilities,and Substance Abuse Services. She can be reached at flo.stein (at) ncmail.net.

“There are many reasons whyindividuals fail to get treatment,including stigma associated withthe disorder, cost of treatment,unavailability of support, andfailure of systems to effectivelyidentify individuals and directthem into treatment.”


P


Treatment in the Context of the RecoveryCommunity

In his monograph Recovery Management, William L. Whiteoutlines the history of the addictions field by describing itsorganizing principles.3 Beginning in 1978, the pathology paradigmdescribes addiction as a disease and breaks with the previousmoral and religious frameworks. This was followed in the1990s by the intervention paradigm that wasmarked by publicinvestment inpreventionandprofessionally directed treatment.The model being proposed now is known as the recoveryparadigm. Recovery advocates began to work for this changestarting in the late 1990s and now, years later, they confront amisguided public perception that peoplewith substance abusedisorders cannot recover. These advocates are joining withelected leaders, policymakers, and treatment professionals toshift the focus from “treatmentworks” to “recovery as a reality.”The movement towards a recovery paradigm is underway.4

Whatmany think about the process of addictionmaybepartof the problem, as many people have a poor understanding ofaddiction. Aswith other diseases, our historical understandingof the addictive process has changed over time. The definitionthathasbeendevelopedby theNational InstituteonDrugAbuseis the one operationalized in the NCIOM report. This definessubstance abuse and dependence as a “biopsychosocial”disorder which means that the nature of the disorder isinfluencedby a combination of biological,medical, psychological,emotional, social, and environmental factors. The disorder isprogressive, chronic, and relapsing. Often substance abusedominates an individual’s life, with a profoundly negativeimpact on the individual and those around him or her.Addiction is defined as a chronic, relapsing brain disease thatis characterized by compulsive substance seeking and use,despite harmful consequences. It is considered a brain diseasebecause drugs can change the brain’s structure and function.These changes can be long lasting and can lead to the harmfulbehaviors seen in people who abuse drugs. As a result ofresearch, we know that addiction is a disease that affectsboth brain and behavior. We have identified many of thebiological andenvironmental factorsandarebeginning tosearchfor the genetic variations that contribute to the developmentand progression of the disease through research supported bythe National Institute on Drug Abuse.5

Access tocare isgreatlyaffectedbybothstigmaandcommonmisunderstandings of the addiction process and of peoplewho have substance abuse disorders. Stigma is the negativelabeling and stereotyping of a groupof individuals that is basedon someobservable trait they share that leads todiscriminationagainst the individuals or society at large. For centuries, societyas a whole has stigmatized individuals with mental andsubstance use illnesses and discriminated against them socially,in employment, and in their efforts to secure necessities suchas housing. Perhaps due to the misconception that substanceabuse is due to a moral failing, substance use illnesses areoften timesmore stigmatized thanmental illnesses. The failureto understand the biological mechanisms and consequences

of drug dependence interferes with these individuals’ abilityto participate in and receive care that may be most effectivein treating their chronic condition.7 Nontherapeutic clinicianattitudes and behaviors may have several sources. Graduatemedical education has been slow to shift from commonly heldsocial beliefs and practice settings often reinforce stereotypes.The Institute ofMedicine of theNational Academies found thatin addition to the personal consequences of ineffective, unsafe,or no treatment for substance abusedisorders, the consequencesare felt directly in the workplace; in the education, welfare, andjustice systems; and in the nation’s economy as a whole.7

Inter-System Linkages

Because of the nature of the disorder, individuals in need oftreatment might appear in various settings, including healthcare, the justice system, welfare and social services, and thejuvenile or education system. Inter-systems linkages thatcould increase the number of individuals able to receivetreatment aswell as the resources available for treatment andprevention have to be developed. Where they already exist,they must be enhanced and maintained. All caregivers musthave informed referral practices and share a commonapproach for identifying the problem and determining themost appropriate treatment. NorthCarolina has the opportunityto develop an interactive system that matches care to need,regardless of the point of entry.

Inter-system issues that contribute to the treatment gapare not limited to the inability of systems to identify and moveindividuals toward appropriate treatment. They also includethe difficulty associated with transferring patient-specificinformation form one system to another. New technologiesrequire new principals and policies to protect privacy andencourage the effective use of patient information to improvecare. Individuals with addictive disorders need an easy–to-read,standard notice about how their personal health information isprotected, confidence that those whomisuse information willbe held accountable, and the ability to choose the degree towhich they want to participate in information sharing.8

Resource Allocation and Financing

Theremust be an improvement in the process of allocatingcurrent resources as well as new resources to make moreeffective treatment and prevention accessible to a largernumber of people who experience or are affected by problemswith alcohol or drugs. Thedevelopment of a standard insurancebenefit that provides for a full continuum of appropriatetreatment and recovery maintenance will increase accessesas well as address the inappropriate cost shifting that nowoccurs between the private and public sectors. Until veryrecently the majority of prevention and treatment has beensupported by and provided in the public sector. The recentpassage in Congress of the PaulWellstone and Pete DomeniciMental Health Parity and Addiction Equity Act of 2008 willpermit the state to strengthen a third-party reimbursement

system, increasing access to care by both public and privatepractioners.

Expanding Treatment and Recovery Options

In an interviewwithWilliamWhite,Westley Clark, directorof the Center for Substance Abuse Treatment discussed theconstruct for the new focus on recovery: “Communitiesacross the country have been concerned about the misuse ofsubstances and the wide range of people affected by suchmisuse. National leaders and local community leadersrecognize that we need the community benefits of recovery,andwe need local communities to support people in recovery.Andwewant to provide a framework through which people inrecovery can help others in need of recovery…Wewant peoplein every community to know that treatment works and thatrecovery is possible, and that long-term recovery is a reality.”9

Not all alcohol and drug problems are chronic andmany donot require specialized treatment. Effective prevention andearly intervention services and programs are essential to themaintenance of a healthy community. One example of amodeldesigned to target users who may have a problem but do notyet recognize it is providing significant opportunities in primarycare and emergency department settings. Screening, BriefIntervention, and Referral to Treatment (SBIRT) is a tooldeveloped for use by the medical community. Once a problemis identified, the medical professional conducts an immediatebrief intervention and those individuals with dependence arereferred for treatment.10 This type of new program can reducethe treatment gap and ensure that there is no “wrong door,”focusing on unidentified users as an important segment of thepopulation to target.

Improving access to long-term recovery will, by necessity,require a partnership among the recovery community, families,professionals, and policymakers. I am urging a commitmentby these partners to do the work to ensure the developmentof a new system of care, or treatment assisted recovery, thatrespects the individual taking responsibility for his or herrecovery while providing the necessary services and supportsfor these individual efforts. A review of the history of thedevelopment of treatment is instructive as it indicates thatmuch of the treatment in this country has been organizedaround an acute caremodel. The effort beginning in the 1940sto convince the public that alcoholism was a disease led tolandmark legislation in the 1970s that set the stage for the riseof an acute care model of community-based, time-limitedaddiction treatment in theUnitedStates. Theonset, course, andresolution of an acute disorder can be intense and disruptive,but it generally leaves no lasting disability or compromise infunctional capabilities. Substance abuse disorders, however,are often not resolved so precisely. William L. White and A.Thomas McClellan, PhD, have written extensively about amore accurate description of addiction as a chronic diseasewhose treatment should mirror the treatment of other chronicdiseases. They argue that the similarities between serioussubstance dependence and other chronic illnesses are striking.

The work of the Task Force on Substance Abuse Servicesunder the direction of the NCIOM is being marked by a piloteffort to move addiction treatment in North Carolina beyondacute biopsychosocial stabilization and patient education andtoward the goal of long-term recovery. This shift from an acutecaremodel toarecoverymanagementmodelwill requirechangesin programmatic and service practices and will require newfinancingstrategies.Thesechangeswill result in improvedaccessto recovery for people in our state. These changes will focuson the following treatment system performance indicators:11

� Attraction: Identifying and engaging individuals andfamilies at an earlier state of problem development(e.g., assertive community education, screening, andoutreach programs).

� Engagement: Enhancing access, therapeutic alliance,and retention (e.g., expedited service initiation, focus onrelationship building and re-motivation, altered policiesrelated to administrative discharge).

� Assessment:Developing protocols that are global, family-centered, strengths-based, and continual.

� Service planning: Transitioning from professionallydeveloped treatment plans to client-directed recoveryplans.

� Service menu: Focusing on services elements that havemeasureable effects on recovery outcomes andexpanding the service menu to include nonclinical,peer-based recovery support services.

� Service duration: Shifting from emergency roommodelsthat emphasize brief, crisis-oriented servicers to recoverymodels that emphasize long-term lower intensityrecovery maintenance services.

� Service location: Extending the reach of services frominstitutional environments to the natural environments ofindividuals and families (e.g., expansion of neighborhood-based, work-based, and home-based services).

� Service relationship: Shifting from a professional expertmodel to a long-term recovery partnership/consultantmodel with a philosophy of choice for individuals andfamilies.

� Continuing care: Shifting from follow-up care as anunfunded afterthought to assertivemodels of continuingcare for all clients regardless of discharge status (e.g.,post-treatmentmonitoring, stage-appropriate recoveryeducationandcoaching, personal linkages tocommunitiesof recovery, early re-intervention when needed, andexpanded use of cell phones and internet for long-termmonitoring and support).

� Relationship to the community: Increasing utilization oflocal recovery support resources in the community(e.g., recovery support groups, recovery communityorganizations, recovery support centers, recovery homessuch as Oxford House, recovery schools, recoveryindustries, and recovery ministries).



We have a historic opportunity to work together toward asystem that supports long-term recovery. Reform for mentalhealth, developmental disabilities, and substanceabuse services

is flexible and can accommodate change and improvement. Arecovery-oriented systemof care invites individuals and familiesto a life of recovery in the community. NCMJ

REFERENCES

1 Substance Abuse and Mental Health Services AdministrationCenter for Substance Abuse Treatment. Changing theConversation, Improving Substance Abuse Treatment: The NationalTreatment Plan Initiative.Washington, DC: US Dept of Healthand Human Services; 2000.

2 North Carolina Division of Mental Health, DevelopmentalDisabilities, and Substance Abuse Services. Community systemsprogress report: first quarter SFY 2008-2009. Raleigh, NC: NCDept of Health and Human Services; 2008.

3 White WL, Kurtz E, Sanders M. Recovery Management. Chicago,IL: Great Lakes Addiction Technology Transfer Center; 2006.

4 White WL. Recovery: the new frontier. Counselor: The Magazinefor Addiction Professionals. 2004;5:18-21.

5 National Institute on Drug Abuse. Drugs, Brains, and Behavior:The Science of Addiction.Washington, DC: National Institutes ofHealth; 2007. NIH Publication No. 07-5605.

6 Corrigan PW, Penn DL. Lessons from social psychology ondiscrediting psychiatric stigma. Am Psychol. 1999;54(9):765-776.

7 Committee on Crossing the Quality Chasm: Adaptation toMental Health and Addictive Disorders. Improving the Quality ofHealth Care for Mental Health and Substance-Use Conditions.Washington, DC: National Academies Press; 2006

8 Leavitt MO. New principles and tools to protect privacyencourage more effective use on patient information toimprove care. Keynote address presented to: NationwideHealth Information Network Forum; December 16, 2008;Washington, DC.

9 White WL. An interview with H. Westley Clark, MD, JD, MPH,CAS, FASAM. In: Perspectives on Systems Transformation: HowVisionary Leaders are Shifting Addiction Treatment Toward aRecovery Oriented system of Care. Chicago, IL: Great LakesAddiction Technology Transfer Center; 2007.

10 White House Office of National Drug Control Policy. Targetingthe Full Spectrum of Drug Users: Screening and Interventions.Washington, DC: US Government Printing Office; 2007.

11 White WL, McClellan AT. Addiction as a chronic disorder.Counselor: The Magazine for Addiction Professionals. 2008;8.

he economic cost of substance abuse in the UnitedStates is estimated to exceed $300 billion annually.1,2

Estimates attempt to assess in monetary terms the damagethat results from the use of alcohol (misuse by adults and anyuse among those under 21) and drugs. These costs includeexpenditures on alcohol- and drug-related problems,decreases in productivity, and opportunities that are lostbecause of substance abuse. Despite this economicburden, only $18 billion was devoted to treatment ofsubstance use disorders in 2001. This amount constitutedonly 1.3%of all health care spending.1 InNorthCarolina, about5% of the total Division of Mental Health, DevelopmentalDisabilities, and Substance Abuse Services funds is spent ontreatment and prevention of substance abuse.3

The ubiquitous nature of substance abuse calls for acomprehensive approach inclusive of prevention, treatment,and relapse recovery. However, the central component of thiscontinuum, prevention, is often underestimated, overlooked,andunderfunded.Herewediscuss theneed for and importanceof prevention, which preventive efforts work, the role ofcollaborative efforts in substance use, and how preventiveefforts can best be implemented. Supporting preventionactivities across the life span and in multiple settingrepresents an important opportunity to reduce substanceabuse and its deleterious outcomes.

Why DoWe Need Prevention?

Substance use and abuse impacts multiple sectors of dailyliving. A significant proportion of domestic violence, sexualassault, violent crime, child abuseandneglect,workplace injury,and other health outcomes are related to substance abuse.2 Forexample, prior to the 2007 opening of a Sam’s Club in easternNorth Carolina, the national chain of membership-only retailwarehouses received 4,000 applications for 160 positions.More than 2,000 applicants did not pass mandatory drugtests, thereby effectively reducing the prospective applicantpool by 50%. Twenty-two percent of the applicants did notpass criminal background checks and, coupledwith applicantswho were not hired due to availability (such as not being able

to work on Saturday or Sunday) Sam’s Club had difficultyfilling its 160 positions from the pool of 4,000 applicants.4

This story is not atypical. More and more, small and largebusinesses and industries along with local and state leadersare confronting the negative economic impact of substanceabuse on the bottom line.

The Sam’s Club example demonstrates one of severalcompelling reasons why prevention must be the cornerstoneof any effort to reduce substance abuse and its relatedconsequences. The example also highlights the problemamong adults and the need to promote prevention effortsbeyond the classroom and into the workplace. At the sametime, reported alcohol and drug use among our nation’s youthcontinues to call for efforts to equip young people with therequisite skills needed to protect against myriad risk factorsfor substance use and other related behavior.

Due to the breadth of strategies and advances in the field,prevention efforts provide a unique opportunity to impact thenegative consequences associated with substance abuse. Forexample, numerous strategies are designed at the individuallevel, but the application or implementation of these strategiescan impact largenumbersof youth throughuniversal applicationamong the general population. This is in direct contrast toindividual treatment interventions that often focus on an

“The ubiquitous natureof substance abuse callsfor a comprehensiveapproach inclusive ofprevention, treatment,and relapse recovery.”

Phillip W. Graham, DrPH, MPH, is a senior public health researcher in the Crime, Violence, and Justice Research Program at RTIInternational. He can be reached at pgraham (at) rti.org.

PhillipA.Mooring,MS,CSAPC, LCAS, is the executivedirector of Families inAction, Inc.Hecanbe reachedatwfapmooring (at) simflex.com.

The Emerging Role of Preventionand Community Coalitions:Working for the Greater Good

Phillip W. Graham, DrPH, MPH; Phillip A. Mooring, MS, CSAPC, LCAS


T

a The research to practice movement is an attempt to promote the implementation of evidence-based prevention strategies.

individual patient or client. Prevention efforts, particularlythose that are universal and population-based, are needed tocombat the growing number of risk factors that increase thelikelihood of substance use, but the adoption of prevention-oriented programs must occur with a clear understanding ofwhat efforts have the best opportunities for success.

What Preventive EffortsWork?

The research to practice movementa and the continuedgrowth of the prevention science field5 have drasticallychanged how andwhat types of prevention programs, policies,and practices are implemented in communities across theUnited States. Unfortunately, however, the adoption andimplementation of evidence-based strategies5 is still in theearly stages of diffusion.6 Some studies suggest that only about30% of middle schools implement evidence-based programs,despite evidence of improved academic performance anddecreased substance use and antisocial behavior.6

Communities have access to several resources to informtheir decision making regarding the appropriate selection ofevidence-based prevention strategies. Both federal agenciesand academic institutions including the Center for SubstanceAbuse Prevention (CSAP), the Department of Education (DE),the Office of Juvenile Justice Delinquency Prevention (OJJDP),and the University of Colorado at Boulder have developed anddisseminated lists of prevention strategies that have beenempirically shown to reduce substance use, violence, and otherrelated behaviors.6 Referenced strategies include individual,school, family, and community-focused interventions thataddress potential participants as a function of their risk.

Over the last decade, several reviewsof prevention strategies(programs, policies, and practices) have been conductedexamining their effectiveness in reducing substance use amongyoungpeople.7-10Although the list of effective preventive effortsis too extensive to list here, effective prevention programs arecharacterized by social skills or competency-based, interactivedelivery, cognitive-behavioral focus, complete dosage, andresistance training skills for teachers.

Thedegree towhich the implementation of evidence-basedprevention efforts is embraced in local communities can bemeasurably improved by the existence of early adopters11whoembrace new innovations. Community coalitions can representthose early adopters who both promote and advocate for theselection and implementation of effective prevention efforts.

What is the Role of Collaborative Efforts inPreventing Substance Use?

One strategy being implemented across the nation toprevent the onset of drug abuse is the creation of community-level substance abuse prevention coalitions. The Community

Anti-Drug Coalitions of America (CADCA), a nationalnonprofit organization founded in 1992 with a mission to“strengthen the capacity of community coalitions to createand maintain safe, healthy, and drug-free communities,”defines these coalitions as formal arrangements for cooperationand collaboration between groups or sectors of a community,in which each group retains its identity but all agree to worktogether toward a common goal of building a safe, healthy,and drug-free community.12 Coalitions are community-drivenand aim to bring local people together to solve local problems.

Community coalitions are usually comprised of parents,teachers, law enforcement officials, religious leaders, healthproviders, and other community activistsmobilizing at the locallevel. Although some coalitions may provide direct services,coalitions work to convene key stakeholders and to establishcollaborative efforts among those stakeholders to address thebroader environmental issues that contribute todrugabuseandunderage drinking. Coalitions work to mobilize communitiesto develop community laws and policies that specificallydiscourage drug abuse and underage drinking, encourage theenforcement of existing laws and policies, disseminateinformation, increase media and public awareness, facilitatethe implementation of evidence-based strategies, andencourage life and social skills training programs.

An increased recognition of the importance of coalitions isalso reflected in North Carolina’s substance abuse preventionefforts. During the 2006–2007 legislative session, the NorthCarolina General Assembly appropriated $800,000 over twoyears to support local substance abuse coalitions—a first forNorth Carolina.13 The program is known as the North CarolinaCoalition Initiative (NCCI), and grants are funded through theNorth Carolina Department of Health and Human Services,Division of Mental Health, Developmental Disabilities, andSubstance Abuse Services (DMHDDSAS) to provide trainingand technical assistance to eight sub-recipient coalitions. TheNCCI’s mission is to reduce substance abuse in communitiesby building the capacity of community coalitions to implementevidence-based, population-level prevention strategies.

Although the reported effectiveness of community-levelcoalitions is mixed,14-17 both anecdotal and empirical evidencesuggest that they can be a viable and sustainable vehicle forcommunity change. For example, the Community RoundTable Coalition of Irmo, Dutch Fork, and Chapin, SouthCarolina reported an 18% reduction in binge drinking over atwo-year period as a result of the coalition’s work.18 Similarly,Boyd and Greenup Champions for a Drug-Free Kentucky inAshland, Kentucky, reported past 30-day marijuana use by12th graders dropped from 33% in 1998 to 22% in 2004. InLansing, Michigan, the CIRCLE Coalition saw rates of alcohol,tobacco, and other drug use decline by more than 50%between the 2001–2002 school year and the 2004–2005school year.12


REFERENCES

1 Office of National Drug Control Policy. The Economic Costs ofDrug Abuse in the United States, 1992–2002.Washington, DC:Executive Office of the President; 2004. Publication No.207303.

2 Harwood HJ; The Lewin Group. Updating Estimates of theEconomic Costs of Alcohol Abuse in the United States: Estimates,Update Methods, and Data. Rockville, MD: National Institute onAlcohol Abuse and Alcoholism; 2000.

3 Stein F. The publicly-funded substance abuse system andbarriers to care. Presented to: The North Carolina Institute ofMedicine Task Force on Substance Abuse Services; October 15,2007; Cary, NC.

4 Murphy T. Sam’s Club faced challenges in finding employees.Rocky Mount Telegram. March 12, 2007:1A.

5 Dusenbury L, HansenWB. Pursuing the course from researchto practice. Prev Sci. 2004;5(1):55-59.

6 Ringwalt CL, Ennett S, Vincus A, Thorne J, Rohrbach LA,Simons-Rudolph A. The prevalence of effective substance useprevention curricula in US middle schools. Prev Sci.2002;3(4):257–265.

7 Botvin GJ. Advancing prevention science and practice:challenges, critical issues, and future directions. Prev Sci.2004;5(1):69–72.

8 Gottfredson DC, Gottfredson GD. Quality of school-basedprevention programs: results from a national survey. J Res CrimeDelinq. 2002;39:3–35.

9 Elliott DS, Mihalic S. Issues in disseminating and replicatingeffective prevention programs. Prev Sci. 2004;5(1):47–53.

10 Hawkins JD, Catalano RF, Arthur MW. Promoting science-basedprevention in communities. Addict Behav. 2002;27(2):951–976.


Coalitions also are getting support from nontraditionalpartners, including the business and industry communities. InWilson,NorthCarolina, tiremanufacturerBridgestone-Firestoneis actively involved in the Wilson County Substance AbuseCoalition. JamesS.Pridgen,managerof theBridgestone-FirestoneWilson plant, says, “Finding qualified employees is a problemacross eastern North Carolina. Sixty percent of potentialemployees cannot pass a drug test or 6th grade mathequivalency test. I have 45 job openings, and I have a reallydifficult time filling them with qualified applicants. For us tosurvive, something like this coalition [WilsonCounty SubstanceAbuseCoalition] has to happen. Current estimates tell us thatit costs us over $100,000 per person to find, hire, and train anew teammate for the Wilson Bridgestone-Firestone plant.While we hire locally, we compete globally. Our product qualityand the safety of our teammates are non-negotiable.We have azero tolerance policy for substance abuse. Despite the sizeableinvestment we make in our teammates, we will not acceptdrug abuse in our teammates. Drug free is a condition ofemployment.”19

This example, like the previous Sam’s Club example,illustrates how illicit substance use/abuse can impact thelives of local citizens and their community. It also reinforcesthe need for locally-driven prevention efforts facilitated bybroad-based private-public community coalitions. We mustbegin to examine howprevention efforts can impact substanceuse across the life span and different settings (e.g., school,community, and the workplace).

How DoWe Implement Prevention Efforts?

We have discussed the importance of selecting evidence-basedprevention strategies and theuseof community coalitionsas viable implementation vehicles, but we have not offered anoverarching approach suggesting how best to implementeffective preventive efforts. Although several models exist,20-22

many communities have not been systematic with regard tothe manner in which they approach implementing preventionefforts. We offer the SAMHSA/CSAP’s Strategic Prevention

Framework (SPF) as an appropriate and effective approach tofacilitate the implementation of preventive efforts in our localcommunities.

Strategic Prevention Framework is a “systematic community-based approach, which aims to ensure that substance abuseprevention programs can and do produce results… The ideabehind the SPF is to use findings from public health researchalong with evidence-based prevention programs to buildcapacity within states and the prevention field.”23 The SPFuses a five-step data-driven process that includes communityassessment, capacity building, planning, implementation, andevaluation, with sustainability and cultural competence beingoverarching elements. Underlying SPF is the assumption thatprevention is not static; rather, it is an ordered set of ongoingsteps.

This model provides a unique opportunity for members ofcommunity coalitions and other stakeholders to select anddeliver the most appropriate evidence-based preventionstrategies in their respective communities. The use of the SPF,evidence-basedpreventionstrategies, andcommunitycoalitionsrepresent a significant development for prevention in NorthCarolina. SPFhelpsmovecommunities away from implementingstrategies with limited evidence of success and focuses themon areas of real need and not perceived need.

In the coming year, the state will be faced with fewer statedollars for substance abuse services. At the same time, economicvolatility and the stresses it will cause may exacerbate theneed for more substance abuse services. The convergence ofless resources and greater need should cause the cliché “anounce of prevention is worth a pound of cure” to resonatewith us all because preventive efforts are our best chance toimprove the conditions of thosewho could become substanceusers in the future. Prevention practitioners, armed with solidevidence, need to vigorously advocate for and promote themerits of preventive efforts to reduce substance abuse. Oneof the best ways to accomplish this is at the local level withthe aid of community coalitions. Local problems are bestsolved by local people. NCMJ

11 Hallfors D, Godette D. Will the “principles of effectiveness”improve prevention practice? Early findings from a diffusionstudy. Health Educ Res. 2002;17(4):461–470.

12 Dean AT. Demand reductions and coalitions: from theWashington beltway to your community. Presented at: The 8thAnnual Michigan Substance Abuse Conference; September 11,2007; Grand Rapids, MI.

13 State DHHS andWake Forest School of Medicine team up totackle substance abuse in local communities [news release].Winston-Salem, NC: Wake Forest University Baptist MedicalCenter; May 16, 2008. http://www1.wfubmc.edu/ncci.Accessed January 13, 2009.

14 Hallfors D, Hyunsan C, Livert D, Kadushin C. Fighting backagainst substance abuse: are community coalitions winning?Am J Prev Med. 2002;23(4):237–245.

15 Harachi TW, Ayers CD, Hawkins JD, Catalano RF, Cushing J.Empowering communities to prevent adolescent substanceabuse: process evaluation results from a risk- and protection-focused community mobilization effort. J Prim Prev.1996;16(3):233–254.

16 Hays CE, Hays SP, DeVille JO, Mulhall PF. Capacity foreffectiveness: the relationship between coalition structure andcommunity impact. Eval Program Plann. 2000;23:373–379.

17 Hollister RG, Hill J. Problems in the evaluation of community-wide initiatives. In: Connell JP, Kubisch AC, Schorr LB, WeissCH, eds. New Approaches to Evaluating Community Initiatives:Concepts, Methods, and Contexts.Washington, DC: The AspenInstitute;1995:127–172.

18 Dean AT. Core competencies that lead to successful andsustainable coalitions. Presented at: The National African-American Drug Coalition Summit; April 6, 2006; Washington,DC.

19 Mooring PA. Prevention of substance abuse. Presented to: TheNorth Carolina Institute of Medicine Task Force on SubstanceAbuse; November 16, 2007; Cary, NC.

20 FeinbergME, GreenbergMT, Osgood DW. Readiness, functioning,and perceived effectiveness of community prevention coalitions:a study of communities that care. Am J Community Psychol.2004;33(3-4):163–176.

21 Bazzoli GJ, Stein R, Alexander JA, Conrad DA, Sofaer S, ShortellSM. Public-private collaboration in health and human servicedelivery: evidence from community partnerships.Milbank Q.1997;75(4):533–561.

22 Foster-Fishman PG, Berkowitz SL, Lounsbury DW, Jacobson S,Allen NA. Building collaborative capacity in communitycoalitions: a review and integrative framework. Am J CommunityPsychol. 2001;29(2):241-261.

23 Substance Abuse and Mental Health Services Administration,Center for Substance Abuse Prevention. SAMHSA’s PreventionPlatform. http://prevention.samhsa.gov/about/spf.aspx.Accessed January 13, 2009.


nited States combat veterans have historically been atrisk for substance use disorders. Following 19th century

medical advances in opiate anesthetics,manyCivilWar soldierswere routinely given opiate doses to manage their pain andfatigue; a great number of these soldiers subsequentlydeveloped a morphine addiction,commonly called the “Soldier’sDisease.”1 About a century later,nearly 8% of Vietnam veteranstested positive for marijuana,opiates, and other substances atdischarge.2

A new cohort of US combatveterans has emerged fromOperationEnduring Freedom (OEF), locatedprimarily in Afghanistan, andOperation Iraqi Freedom (OIF),located primarily in Iraq. As ournation’s combat operations moveinto their seventh year—continuinglonger than World War II—1.6 millionmen and women have served in Iraqor Afghanistan as part of America’sall-volunteer fighting force.3 Up to75%ofdeployed troopshaveenduredtwo or more deployments during thecurrentconflict.Repeatedand extendeddeployments have beenassociated with increased physical andmental health concerns.4

As nearly 10% of all US Active Duty and 3% of all US Reservemilitary personnel reside in North Carolina,5 the mental healthneeds of this growing veteran population is especially salientto the North Carolina mental health care community.

Substance Use Among OEF-OIF Veterans

Anecdotal accounts from clinicians and the media (forexample,ABC’s 20/20series,ComingHome: Soldiers andDrugs

andUsher, 20066) allude to problematic alcohol consumption,tobacco use, and illicit substanceusebeginningduringmilitarytrainingand increasingduringcombatdeployment.Manymilitarypersonnel see drinking heavily as a right of passage or as partof their military culture. Veterans commonly report steroid

use in response to perceived challenges to meet physicalperformance measures, as well as use of illicit stimulant andsedatives to relieve boredom, cope with stress, and meetperformance demands during deployment. Many describesmoking cigarettes as a way to pass time. Often, what maystart as a social practice or coping strategy can become anaddiction.

Post-deploymentmeasures ofmental health status completedby the Department of Defense (DoD) evidence problematicalcohol use following deployment. Pre-deployment dataindicates that approximately 8% of military service members

“Manymilitary personnel seedrinking heavily as a right of

passage or as part of their militaryculture…Many describe smokingcigarettes as a way to pass time.Often, what may start as a socialpractice or coping strategy canbecome an addiction.”

A. Meade Eggleston, PhD, is a psychology fellow at the Veterans Affairs Mid-Atlantic Mental Illness, Research, and Clinical Center(MIRECC). She is affiliated with the Department of Veteran Affairs Medical Center in Durham, North Carolina. She can be reached ateggleston (at) biac.duke.edu.

Kristy Straits-Tröster, PhD, ABPP, is the assistant clinical director at the Veterans Affairs Mid-Atlantic Mental Illness, Research, andClinical Center (MIRECC). She is affiliated with the Department of Veteran AffairsMedical Center in Durham, North Carolina and theDepartment of Psychiatry and Behavioral Sciences at Duke University.

Harold Kudler, MD, is the associate director of the Veterans Affairs Mid-Atlantic Mental Illness, Research, and Clinical Center(MIRECC). He is affiliated with the Department of Veterans Affairs Medical Center in Durham, North Carolina and the Departmentof Psychiatry and Behavioral Sciences at Duke University.

Substance Use Treatment Needs AmongRecent VeteransA. Meade Eggleston, PhD; Kristy Straits-Tröster, PhD, ABPP; Harold Kudler, MD


U

engage in heavyweekly drinking, 45%engage in bingedrinking,and 11% report at least one alcohol-related problem.7 Recentanalysis of longitudinal data gathered by the DoD reveals that12%of activemilitary and 15%of National Guard and Reservemilitary servicemembers drankmore than theymeant to drinkor felt theneed tocutdownwithin sixmonthspost-deployment.8

Furthermore, National Guard and Reserve military servicemembers who deploy and report combat exposure are atsignificantly increased risk for new-onset, heavy weeklydrinking, binge drinking, and alcohol-related problems.7

Alcohol and other substance use problems persist past theperiod of active military service. Among OEF-OIF veteransseenatVeteransAffairs (VA)hospitals andclinics in2005,40%screened positive for potentially hazardous alcohol use on athree-item alcohol consumption measure (AUDIT-C).9 Amongthe nearly 350,000 OEF-OIF veterans who have presented tothe VA between FY 2002 and FY 2008, approximately 16%received a provisional diagnosis of nondependent alcohol orother substance abuse, 4% of alcohol dependence, and 2%other substance dependence.10Another 11%of these veteranshave a diagnosis of tobacco use disorder without othersubstance use diagnoses. A retrospective study examiningconfirmed mental health diagnoses in a sample of 103,788OEF-OIF veterans seeking VA care found 5% received asubstance use disorder diagnosis.11 Neither of these studiesincluded veterans who seek care through the Vet Centers,which operate independently from VA medical centers andVA community outpatient clinics.Moreover, OEF-OIF veteranswho sought VAhealth care constitute only 40%of all OEF-OIFveterans eligible for care, so the true prevalence of substanceabuse disorders among all OEF-OIF veterans is unknown.

While US national trends show decreasing tobacco use,higher rates of tobacco use have been reported both withinOEF-OIF Active Duty cohorts and VA cohorts. In surveys ofmilitary personnel deployed to Iraq and Afghanistan, 39%smoked 10 or more cigarettes daily during their deploymentand 42-48%either began smoking or resumed smoking duringthe deployment.12,13 Initiating smoking during deployment wasrelated to combat exposure, while smoking relapse wasassociated with combat exposure, multiple deployments, anddeployments enduring longer than nine months.13 Littleresearch has been conducted on the use of smokeless tobacco.

Posttraumatic stress disorder (PTSD) and traumatic braininjury (TBI) are prevalent conditions in this veteran cohort andare likely to exacerbate the severity and course of substanceuse problems. PTSD is an Axis I mental health diagnosis,referring to its status as a clinical condition, versus Axis IIdiagnoses, which refer to underlying and pervasive conditionssuch as mental retardation. PTSD is the most common Axis Idiagnosis among theOEF-OIF combat veterans,with prevalenceestimates ranging from 13-22% of those presenting to VA.10, 11

High rates of substance use disorders and PTSD comorbiditywere first reported inwar-related studies, inwhich asmany as75%of Vietnamwar combat veteranswith lifetime PTSD alsomet criteria for alcohol abuse or dependence.14Amongmen inthe general population with a lifetime history of PTSD, 35%

report drug abuse or dependence at some point in their livesversus 15% of men without PTSD. For women, 27% with alifetime history of PTSD report drug abuse or dependenceduring their lives versus 8% of women without PTSD.15 In alongitudinal study of Vietnam veterans, researchers foundthat the onset of alcohol abuse was associated with the onsetof PTSD.16 Increases in alcohol use paralleled the increase inseverity of PTSD symptoms.

The combination of substance dependence and PTSD is asignificant clinical problem. Substance dependent individualswith PTSD are more likely to report suicidality, aggression,and psychosocial impairment at treatment onset than arethose with other Axis I conditions (excluding PTSD) or thosesuffering from substance dependence alone.17 In a multisite,treatment outcome trial, Ouimette and colleagues found thatmale veterans with both PTSD and a substance use disorderrequired twiceasmuch time toachieveequivalent improvementsin substance use, other psychiatric symptom severity, andpsychosocial functioning compared to those with other Axis Iconditions (excludingPTSD)or those suffering fromsubstancedependence alone.18-20

With improved military and medical technology, many ofour recent veterans survive head injuries that would havekilled veterans from previous cohorts. Consequently, TBI hasbeen estimated to affect 20-30% of OEF-OIF survivingcasualties.3Available findings suggest that rates of substanceabuse increase among casualties over time since injury andpre-injury alcohol and other substance abuse substantiallyincreases risk for subsequent substance use problems.21

Although TBI injury areas vary with impact characteristics,combat and motor vehicle accident injuries typically involvethe frontal lobes. This part of the brain influences impulsecontrol, decision making, and emotional inhibition, amongother significant functions. Injury-related cognitive deficitspresent a significant challenge in managing alcohol and othersubstance use. Moreover, emotional-behavioral vulnerabilitieslike PTSD and environmental stressors like the deploymentcycle itself further complicate clinical presentation. Given thatPTSD is strongly associated with even mild TBI (concussion)among OEF-OIF veterans,22 clinical complications are to beexpected.

Clinical Needs Among OEF-OIF Veterans

Increase and improve the capacity of the substance usetreatment system in North Carolina to provideevidence-based care

The Veterans Health Administration (VHA) is a leader inpromoting evidence-based treatment and, accordingly, VAsubstance use treatment guidelines for primary care andspecialty clinics mandate provision of these treatments.23

Although effective substance use disorder treatment isoffered through the VA, there has been a substantial declinein the number of specialized VA substance use treatmentprograms and staff, from 389 programs and 4,718 staff in FY1994 to 215 programs and 2,427 staff in FY 2003.24 This decline


occurred during a period in which the number of VA patientsdiagnosedwith substance use disorders increased.25 Integrationof substance services within VA primary care programs couldpotentially fill this service gap. A base of growing empiricalliterature supports the efficacy of brief alcohol misuse andtobacco screening and interventions within primary caresettings.26,27 Recent evidence suggests, however, that primarycare providers feel ill-equipped to treat substance usedisordersand typically refer such patients to specialty clinics.28 In fact,data show that only 31%of the large portion (40%) ofOEF-OIFveterans who screened positive for potentially hazardousalcohol use reported having been advised by their doctorto reduce their drinking.9 Furthermore, there is no researchsupporting the efficacy of brief screening and interventionsfor illicit substance use within nonspecialty settings.

Since 2003, the number of VA specialized substance usetreatment programs has grown but has not attained previouslevels.29 Data also suggest inadequate service delivery byprivate and public sectors, as only 9% of all people needingalcohol or other substance use treatment receive treatment.30

Thus, an opportunity exists for VA and state substance useprograms to work together to increase substance use capacityandaccess forOEF-OIF veterans and their families.While 2-5%of alcoholics, smokers, and other substance dependentpatients remit each year, even without treatment, the restcontinue to need substance use treatment.31 The demand forsubstance use treatment services can only be expected togrow as OEF-OIF veterans age. Thus, long-term planning tosupport the needs of these veterans and their families shouldbegin now as a separate component of a concerted VA/stateplan. Provision of adequate substance use treatment servicesis cost-effective. Untreated alcohol or drug dependent peopleincur health care andother costs at nearly twice the rateof theirage and gender peers; however this trend begins reversingat treatment initiation.32,33 Intensive outpatient treatment hasbeen shown across studies to demonstrate the greatest cost-benefit ratio. Moreover, and of particular relevance to OEF-OIFveterans, age differences in costs support the value of earlyintervention

Include tobacco cessation programming within primarycare and substance use treatment

As tobacco abuse and dependence are themost lethal andcostly substance use disorders in the US, routine tobacco usescreening and effective smoking cessation treatment will alsopromote health andwell-being among this cohort of veterans.As with alcohol and other substance use disorders, the VAmandates evidence-based treatment for tobacco users.34 TheVA has been particularly successful making tobacco cessationresources available. By integrating a clinical assessmentreminder into the computerized medical records system,more than 95% of VA users who are smokers are screenedannually for tobacco use and advised to quit.35 VHA primarycare andmental healthprovidersmustmake smoking cessationmedications, such as nicotine replacement therapies, availableto veterans whowant to stop quitting. Furthermore, a toll-free

tobacco cessation support line (800.QUIT.NOW) is promotedand used throughout the VA system. In January 2006, the VAeliminated all copayments for smoking cessation counseling.The VA continues to expand services including telephonecare for veterans willing to set a quit date with their primarycare providers. Community providers could significantlyimprove OEF-OIF veteran care by assessing for tobacco useduring routine exams and eithermirroring these interventionsor referring veterans using tobacco to the VA system forfollow-up care as appropriate.

Provide integrated treatment for substance use disorders,PTSD, and TBI

Because of high rates of comorbid substance use, PTSD,and TBI expected in the OEF-OIF veteran cohort and thepotential interactions between these problems, integratedtreatments may provide better outcomes than treatmentplans that address these problems separately and, typically,sequentially. A large body of evidence finds that untreatedPTSD may adversely affect the treatment of substance usedisorders (i.e. Brown et al, 1999 and Hien et al, 2000).36,37

Moreover, integrated therapy for substance use disorders andPTSD may improve outcomes of both disorders.38,39 Nostandardized or evidence-based treatment exists for treatingall three conditions concurrently. Future investigations intotheir interplay and impact on treatment would advance themental health field and veteran care.

Advance community partnerships with theDoD/VA continuum of care

Active Duty military members who separate from serviceand National Guard and Reserve service members who havereturned from deployment are eligible for VA health carewithout copay for five years for any condition which their VAclinician deems likely to be related to their service in a combatarea. Veterans whose medical problems are subsequentlydetermined to be service-connected will continue to receivetreatment without copay indefinitely. The VA, in collaborationwith the DoD, has implemented outreach efforts to provideinformation about VA services to new veterans immediatelyprior to and following deployment and again 90-180 days afterreturn from deployment as part of a routine Post-DeploymentHealth Reassessment (PDHRA).

While theDoD/VAcare continuumprovides a comprehensiverange of substance use treatment and other medical servicesfor military members and OEF-OIF veterans, partnershipsbetween community health services and VA and DoD healthcare systems are still needed in order to maximize access toand quality of care for the men and women who have servedour country. Notably, although family members of activecomponentmilitarymembersmay obtain theirmedical serviceson base within the same facilities as domilitarymembers, thefamilymembers of Reserve componentmilitarymembers andveterans do not have this option. These divisions in the care ofindividual family members across systems pose an obstacleto integrated efforts to support themilitarymember/veteran by



supporting his or her family. In addition, because of the powerfulstigma associated with seeking mental health care in militarysettings,4 many OEF-OIF veterans and their family membersseek care through communitymental health clinicians, primarycare providers, or clergy.40 These formidable and persistentobstacles to integrated care could be addressed throughinteragency training, cooperation, and communication.Whencliniciansandadministrators coordinateefforts across systems,they significantly improve the quality and availability of services.North Carolina has already taken the lead in developing thiskind of DoD/VA state and community partnership and nowserves as a model for other states.40 Among the key elementsof this system are the toll-free, 24-7 telephone-based NCCareLine accessible at 800.662.7030 (English/Spanish) or

877.452.2514 (TTY) and the web-based NC CareLink athttp://www.NCcareLINK.gov. Both resources offer OEF-OIFveterans and their families easy access to a broad array ofservices including substance use services.

Taken together, these steps comprise a multisystem,interdisciplinary, public health approach to the substance useand mental health problems of OEF-OIF veterans, which isinformed by research on their psychosocial needs andevidence-based approaches to their treatment. Suchmeasuresare necessary to ensure that veterans of ourmost recent warswill, along with their families, gain from what has beenlearned in our nation’s experience with past generationsrather than simply repeat those experiences. NCMJ

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2 Virgo KS, Price RK, Spitznagel EL, Ji THC. Substance abuse as apredictor of VA medical care utilization among Vietnamveterans. J Behav Health Serv Res. 1999;26(2):126-139.

3 Tanielian T, Jaycox L, eds. Invisible Wounds of War: Psychologicaland Cognitive Injuries, Their Consequences and Services to AssistRecovery. Santa Monica, CA: RAND Corporation; 2008.

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13 Smith B, Ryan MA, Wingard DL, et al. Cigarette smoking andmilitary deployment: a prospective evaluation. Am J Prev Med.2008;35(6):539-546.

14 Kulka RA, Schlenger W, Fairbank JA, et al. Trauma and theVietnamWar Generation: Report of Findings from the NationalVietnam Veterans Readjustment Study. New York, NY:Brunner/Mazel; 1990.

15 Kessler RC, Sonnega A, Bromet E, Hughes M. Posttraumaticstress disorder in the National Comorbidity Survey. Arch GenPsychiatry. 1995;52(12):1048-1060.

16 Bremner JD, Southwick SM, Darnell A, Charney DS. ChronicPTSD in Vietnam combat veterans: course of illness andsubstance abuse. Am J Psychiatry. 1996;153(3):369-375.

17 Eggleston AM, Calhoun PS, Svikis DS, Tuten M, ChisolmMS,Jones HE. Suicidality, aggression, and other treatmentconsiderations among pregnant, substance dependent womenwith posttraumatic stress disorder. Compr Psychiatry. In press.

18 Ouimette P, Brown P, Najavits L. Course and treatment ofpatients with both substance use and posttraumatic stressdisorders. Addict Behav. 1998;23(6):785-795.

19 Ouimette PC, Ahrens C, Moos RH, Finney JW. Posttraumaticstress disorder in substance abuse patients: relationship toone-year posttreatment outcomes. Psychol Addict Behav.1997;11(1):34-47.

20 Ouimette PC, Finney JW, Moos RH. Two-year posttreatmentfunctioning and coping of substance abuse patients withposttraumatic stress disorder. Psychol Addict Behav.1999;13(2):105-114.

21 Parry-Jones BL, Vaughan FL, Cox MW. Traumatic brain injuryand substance misuse: a systematic review of prevalence andoutcomes research (1994–2004). Neuropsychol Rehabil.2006;16(5):537-560.

22 Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, CastroCA. Mild traumatic brain injury in US soldiers returning fromIraq. N Engl J Med. 2008;358(5):453-463.

23 DoD/VA Clinical Practice Guideline Working Group, VeteransHealth Administration, Department of Veterans Affairs andHealth Affairs.Management of Substance Use Disorders inPrimary and Specialty Care.Washington, DC: Dept of Defense;2001. Office of Quality and Performance Publication No. 10Q-CPG/SUD-01.

24 Tracy SW, Trafton JA, Humphreys K. The Department of VeteransAffairs Substance Abuse Treatment System: Results of the 2003Drug and Alcohol Program Survey. Palo Alto, CA: ProgramEvaluation and Resource Center and Center for Health CareEvaluation; 2004. www.chce.research.med.va.gov/pdf/2004DAPS.pdf. Accessed December 1, 2008.

25 Dalton A, Saweikis M, McKellar JD. Health Services for VASubstance Use Disorder Patients: Comparison of Utilization FiscalYears 2005, 2004, 2003, and 2002. Palo Alto, CA: ProgramEvaluation and Resource Center; 2004.www.chce.research.med.va.gov/pdf/2005yellowbook.pdf.Accessed December 1, 2008.

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onsider these scenarios:� Colleagues in a large medical practice believe they

smell alcohol onaphysician’s breath in theworkplace.� A physician with back pain reads an article in the

North Carolina Medical Board Forum about theNorth Carolina Physicians Health Program (NCPHP),becomes concerned about her use of opiates, andrealizes she needs help.

� A hospital reports a physician to the North CarolinaMedical Board (NCMB) and to NCPHP because ofongoing sexual harassment of other staff.

� A physician assistant self-reports to NCPHP beforehis practice dismisses him for continual abusivecomments and actions towards patients.

While the actual cases monitored by NCPHP are not usuallythis simple, all of these examples have in fact been seenmanytimes. This is because the North Carolina General Assemblyand a number of other visionary leaders in thisstate fought strong opposition to establish apeer assistance program in the 1980s forphysicians who needed help.

TheNorthCarolinaPhysiciansHealthProgramis proud of its over 20 years of service. Since itsfounding on December 1, 1988, over 2,000physicians, physician assistants, veterinarians,and registered veterinary technicians havebeenseen for substance abuse assessment. As aresult, numerouspractitioners seeking recoveryare now visited regularly by field coordinatorsfor urine drug screens and supportive services.

The first movement toward a physician’shealth program began in 1978 through thework and foresight of pioneers in this field. Dr.Ted Clark, Dr. Jonnie McLeod, Dr. Harold Godwin, and manyothers started the Physicians Health and EffectivenessCommittee, part of the North CarolinaMedical Society, in themid-1970s. These individuals believed that many physicianssuffering from substance use or mental health problemsdeserved help and treatment, not solely sanction or loss of amedical license. Significant resistance was encountered frommany in the profession who did not understand that recovery

frommental health and substance abuse problems is possiblethrough treatment andmonitoring. However, Ted Clark and hiscolleagues believed that the doctorswho found recovery couldbe of greater service to patients, in part because they hadsuffered from a chronic but treatable disease.

From 1978 until 1988, Dr. Clark operated the Committeeout of his home. It was during this time that attitudes towardtreatment began to change. By 1987, the North CarolinaGeneral Assembly authorized the North Carolina MedicalBoard and the North Carolina Medical Society to create apeer-review process. Senate Bill 204, later to become part ofNC General Statute 90-21.22, formalized the work of theCommittee. NCPHP, first known as the Physicians Health andEffectiveness Program, was born.

Physicians and physician assistants (PAs)may seek servicesfromNCPHP on their own or through a referral. Thoughmanyreferrals come from the NCMB and hospitals, others comefrom a wide range of sources including residency directors,

colleagues, treatment centers, and spouses. The types ofinterventions are related to the types of problems and theyare broadly classified into five types (see Table 1).

Analysis of the chemical dependence files shows thatNCPHP has an approximate 90% positive outcome rate atfive years after intake. This exceeds or matches the nationalstandard for chemical dependence monitoring.1 These resultsspeak for themselves.

Physician Health vs. Impairment:The North Carolina Physicians Health Program

Warren Pendergast, MD; Jim Scarborough, MDiv

Warren Pendergast, MD, is medical director and CEO at North Carolina Physicians Health Program.

Jim Scarborough,MDiv, is director of professional operations at the North Carolina Physicians Health Program. He can be reached atinfo (at) ncphp.org.

“We, as physiciansand PAs, have a responsibilityto ourselves, our profession,our colleagues, and to ourpatients to assist each otherin getting timely help.”

C

Dr. Jonnie McLeod, writing in the North Carolina MedicalJournal in 1996, reflected on the first decade of work. She said,“…a large fraction of the medical community still insists thatimpaired physicians ought to be punished rather than helpedto recover. Those of us who have seen the results know thatdespite the years of struggle, this program ismore thanworthit.”2

So what has not changed in the last 20 years? The followingproblems remain largely unresolved:

� Physicians/PAs suffer fromaddiction at the same rate, orperhaps only slightly higher, as the general population.

� Denial and fear often prevent physicians/PAs fromgettingearly treatment.

� Physicians/PAscontinue toencounter external obstaclesto treatment.

� A significant amount of the illness suffered by physiciansand PAs results in relapse.

� Societyremainsambivalentas towhethersomeconditions(especially substance abuse and perhaps depression)represent moral failing, weakness, or illness. This is anespecially sensitive issue as it relates to health careprofessionals.

Many of the issues that have made it difficult to estimatethe prevalence of psychiatric illness in the general population3,4

also affect the accuracy of information about prevalence inprofessionals.5 In addition, denial and fear of professionalconsequences in physicians not only interferes with access totreatment, but alsomakes the issue very difficult to study. Thedefinition of a “good outcome” has been hotly argued. Somesay that a single slip, relapse, or even theminimal presence ofaddiction in health care professionals is unacceptable. Otherspoint to the 1956 and 1987 declarations by the AmericanMedical Association that alcoholism and drug dependenceare illnesses; they argue that addiction treatment should beapproached like diabetes or heart disease, and be treatedusing a chronic disease management model. This dichotomyhas existed in various forms throughout NCPHP’s history.

What things have changed in the last 20 years?� Physicianhealthprograms(PHPs)havebecomewidespread

throughout the US and Canada, now existing in someform in most states and provinces.

� Many PHPs have begun to address other psychiatricdiagnoses, behavioral issues, and professional sexualmisconduct.

� More research is available on factors leading to favorableaddiction outcomes in physicians/PAs.6

� The definition of “acceptable risk” has shifted and/ornarrowed.

� Regulatory, legal, and financial pressures inmedicinehaveincreased greatly, with increased calls for transparency inthe regulatory process and greater pressure onmedicalboards and other regulatory bodies.

� Computers and the internet have markedly changedthe collection and dissemination of information.

� Tension inmedicinebetween“high-touch”and“high-tech”has increased.

� Use of medications for treatment of psychiatric illnessand addiction has become more widespread andaccepted.

� There is a greater understanding of the anatomy andphysiology of addiction.

� Drug screening technology has advanced, as havemethods for evasion of detection.

� Programs now exist for many other professionals inNorthCarolina, including nurses, attorneys, pharmacists,and dentists.

Noneof these changeshaveoccurredovernight; all representthe evolution of trends that have developed over many years.While this slow process often makes it hard to see “the forestfor the trees” at any given point in time, we ignore the trendsat our peril.

Physician health programs throughout the US and Canadahave operated under many different models: some have beenoperated by medical boards, some by medical societies, andothers as independent programs. NCPHP was set up early inits history to be independent but with internal “checks andbalances” involving the NCMB, NCMS, and other stakeholders.The underlying idea was to maximize both patient safety andphysician/PA health.

NCPHP monitoring contracts are structured so that (forcases not known to theNCMB) anonymity ismaintained as longas the participant is safe to practice. However, if the participantconstitutes an imminent danger to the public or themselves,refuses to cooperate with the program, refuses to submit totreatment, is still impaired after treatment, or if it reasonablyappears that thereareother grounds fordisciplinaryaction, theirstatus is made known to the NCMB. Pursuant to longstandingNCPHP policy, and now due to changes in the NC GeneralStatutes, professional sexual misconduct cases are onlymonitored with mandatory involvement of the NCMB.

Impairment has been defined by the Federation of StateMedical Boards as, “the inability of a licensee to practicemedicine with reasonable skill and safety by reason of: mentalillness; physical illness or condition, including but not limitedto those illnesses or conditions that would adversely affectcognitive,motor, or perceptive skills; habitual or excessive use

Table 1.NCPHP Assessments 1988-2007

Chemical Dependence and Dual Diagnosis 59%

Psychiatric (Axis I) 12%

Behavioral (Axis II) 12%

Unsubstantiated and Other 12%

Professional Sexual Misconduct 5%


or abuse of drugs defined in law as controlled substances,alcohol, or other substances that impair ability.”7 By thisdefinition, illness can lead to impairment but is not the samething as impairment.

There will always be tension between the goal of gettingpractitioners to self-identify illnessearly and to seekhelp versusthe desire of the public to know when their doctor is ill orimpaired. The former emphasizes protection of the publicthroughprevention,while the latter speaks to theempowermentof patients as consumers.

The lessons of the last 20 years have taught that PHPsmust address both illness and impairment and, ideally, evenconditions predisposing to illness. A prevention model willonly work if practitioners feel safe in getting early preventivetreatment and monitoring of illness through the PHP. If thedefinitions of illness and impairment become confused, thatperception of safetywill be eroded. The PHPwill then getmoreand more referrals of those in late-stage addiction and hencethosewhoaremore likely to be impaired in theworkplace. Thisbecomes a vicious cycle that ultimately results in the inabilityof the PHP to function effectively, to the detriment of publicsafety.

Furthermore, if the bar to return to practice after addictiontreatment is set too high, physicians and PAswill be evenmorereluctant to get treatment. If the bar is set too low, physicians

and PAs will return to work too early and/or with inadequatetreatment. NCPHP’s role, in part, is to assess the severity ofillness, help determine appropriate length of treatment, andto assess the potential to practice safely, and to do so in asunbiasedandobjective amanner aspossible. Thequestion is oneof balance. A recentNCPHPparticipantwas told by a colleagueduring his intervention, “You can make the decision to go totreatment now, or you will reach a point where others aremaking decisions for you, and you won’t like the outcome.”

In achieving this balance, physician health programs havea responsibility to carry out our mission as consistently andcompetently as possible.While it is not realistic to expect thecomplete absence of errors, policies must be in place tominimize the chance of errors taking place and to identify andcorrect mistakes when they occur.

How society treats its physicians and PAs will determinehow those practitioners treat their patients.We, as physiciansand PAs, have a responsibility to ourselves, our profession,our colleagues, and to our patients to assist each other ingetting timely help. NCPHP has helped the profession do justthat for 20 years and looks forward to the next 20 years andbeyond. As an NCPHP participant recently said, “The valueof a benevolent act such as this cannot be underestimated,and I continue to be grateful to those who made this miraclepossible.” NCMJ

REFERENCES

1 Ganley OH, Pendergast WJ, Wilkerson MW, Mattingly DE.Outcome study of substance impaired physicians and physicianassistants under contract with North Carolina PhysiciansHealth Program for the period 1995-2000. J Addict Dis.2005;24(1):1-12.

2 McLeod, JH. Our brother’s keeper. A history of the North CarolinaPhysicians Health Program. NCMed J. 1996;57(4):201-202.

3 Regier DA, Myers JK, Kramer M, et al. The NIMHEpidemiologic Catchment Area program: historical context,major objectives, and study population characteristics.Arch Gen Psych. 1984;41(10):934-941.

4 NarrowWE, Rae DS, Robins LN, Regier DA. Revised prevalenceestimates of mental disorders in the United States: using aclinical significance criterion to reconcile two surveys’ estimates.Arch Gen Psych. 2002;59(2):115-123.

5 Hughes PH, Brandenburt N, Baldwin DC Jr, et al. Prevalence ofsubstance use among US physicians. JAMA.1992;267(17):2333-2339.

6 Domino KB, Hornbein TF, Polissar NL, et al. Risk factors forrelapse in health care professionals with substance use disorders.JAMA. 2005;293(12):1453-1460.

7 Federation of State Medical Boards. Report of the Ad HocCommittee on Physician Impairment. http://www.fsmb.org/pdf/1995_grpol_Physician_Impairment.pdf. Accessed November19, 2008.


t may not be a surprise to learn that the majority of NorthCarolina’s offender population has been identified as having

problemsassociatedwith substance abuse.1Without professionalintervention, using some potentially harmful substancesoften escalates into abuse and/or dependency and is a majorfactor in criminal behavior, leading to arrest, re-arrest, andincarceration. According to the Office of National DrugControl Policy, drug therapy while in prison andunder post-incarceration supervision can producea 50% reduction in criminal recidivism.2 Nationalstudies indicate that more than 65% of releasedstate prisoners are expected to be rearrested for afelony or serious misdemeanor within three yearsafter release.3 More than 95% of prisoners returnto the community, usually within two years,2 andoften forego the opportunity to voluntarily engagein community-based substance abuse treatmentservice. Therefore, in the interest of public healthand safety, and in an effort to reduce both thehuman and financial cost of incarceration, it iscritical that North Carolina continue in its effortsto provide a comprehensive array of substanceabuse treatment services for offenders andinmates within the North Carolina Department ofCorrection (NC DOC).

Creating a Substance Abuse Program

In 1987, a North Carolina Legislative ResearchCommission reported to the General Assemblythat:4

� Over67%ofcriminaloffensesdirectlyconnectto alcohol and drug use.

� Treating addiction is imperative as mostoffenders eventually leave prison.

� Punishment alone does not work to prevent recidivism.

A resulting proposal by the Commission led to legislationthat created the North Carolina Department of Correction’sDivision of Alcoholism and Chemical Dependency Programs(DACDP).

Organization andMission

DACDP was established in 1988 and is one of four majordivisions of the North Carolina Department of Correction.The Division is responsible for the delivery of comprehensiveinterventions, programs, and services to both male andfemale offenders who have alcohol and/or drug problems.

The Division’s programming reflects “best practices” forintervention and treatment, as established by the NationalInstitute on Drug Abuse (NIDA) and the Substance Abuseand Mental Health Services Administration (SAMHSA). Itsprogramsarebasedonprovencognitive-behavioral interventions,which challenge criminal thinking and confront the abuse andaddiction processes as identified by program participants. Inaddition, the Division provides information and education on

Substance Abuse Treatment Continuum inthe North Carolina Department of CorrectionVirginia Price

Virginia Price is the assistant secretary for the Division of Alcoholism and Chemical Dependency Programs in the North CarolinaDepartment of Correction. She can be reached at pvn02 (at) doc.state.nc.us.

“…in an effort to reduce boththe human and financial costof incarceration, it is criticalthat North Carolina continuein its efforts to provide acomprehensive array ofsubstance abuse treatmentservices for offendersand inmates within theNorth Carolina Department

of Correction.”

I


traditional recovery resources available to offenders bothwhile in prison and upon return to the community.

Scope of the Problem

In 2003, the Division implemented the Substance AbuseSubtle Screening Inventory (SASSI), which was normed forthe North Carolina prison population. DACDP uses thisscreening tool to identify inmates with a high probability of asubstance use disorder and to assign a severity level. DuringFY 2006-2007, DACDP administered the SASSI to 23,111newly-admitted inmates. Of the new admissions screenedfor this fiscal year, nearly 63% or 14,582 individuals wereidentified as in need of brief, intermediate, or long-termtreatment services.1

Array of Services

The Division operates treatment programs in 18 minimumandmediumsecurity prisons and has contractswith twoprivateproviders. An additional facility serves 300male probationersand parolees. The 21 programs provide 1,485 treatment slots,containedwithin program cycles that complete several times ayear. In FY 2006-2007, 5,112 offenders successfully completedtreatment programs offered by the Division and its contractpartners.Many of those offenders continue their treatment inaftercare programs offered by theDivision or inweekly self-helprecovery groups within the prison.

Prison-Based Programs

DACDPadministrative and clinical staff operate prison-basedsubstanceabuse treatment programswithin selectedminimumandmedium custody prison facilities. Residential and programspace for program participants is maintained separately fromthe regularprisonpopulation.DACDPadministers the treatmentprogramwhile the Division of Prisons (DOP) is responsible forall matters pertaining to custody, security, and administrationof the prison facility.

Eligibility for DACDP prison-based treatment programs isestablished during diagnostic processing with the administeringof the SASSI. Upon an inmate’s admission to a treatmentlevel, the DACDP staff also completes a thorough clinicalassessment, which examines major life areas to further definethe history and extent of the substance abuse problem.Together, these measures establish the final recommendedtreatment placement for programparticipants.

Programs are based on cognitive-behavioral interventions(CBI) and encompass three service levels: brief intervention,intermediate treatment, and long-term treatment services.DACDP brief intervention programs consist of 48 hours ofintervention servicesover aneight-weekperiod, introducing therecovery process to inmates. Intermediate treatment programsvaryinlengthfrom35-180daysandarelocatedin14prisonfacilitiesacross the state. Long-term treatment programs of 180 daysto one year operate in four prisons and are designed to treat

seriously addicted inmates who need intensive treatment withinthe prison system.

TheDepartmenthascontractualagreements for theprovisionof long-term treatment with two private facilities: EvergreenRehabilitation Center for males and the Mary Frances Centerfor females. Eligibility is more restrictive at the private facilities;inmates must be at least 19 years old, in good health, withoutdetainers or assaultive crimes, and be infraction-free for 90days prior to entry.

Ideally, long-term program completion coincides with thecompletion of the prison sentence, and the inmate is providedrecommendations for community-based aftercare. Whenadditional time remains on the sentence, the inmate completingtreatment returns to the regular population and is encouragedto participate inDACDP aftercare. Operating in several prisonlocations, aftercare services offer a formal 8-12 week trackdesigned to help the inmate transition to the general populationand remain in recovery. An additional 12-week pre-releasecomponent is also available for inmates approaching releasewho indicate a need for renewed focus on recovery planning.Inmates learn that recovery does not come about as the resultof treatment but as the result of hard work on real issues astreatment services decrease.

Community-Based ResidentialTreatment Programs

DACDPoperatesDART-Cherry (Drug andAlcohol RecoveryTreatment), a residential treatment facility in Goldsboro formale probationers and parolees. Judgesmay order participationin this program as a condition of probation or the state’sparole commission may order participation as a condition ofparole or post-release supervision. It is mandated by statute(GS § 15A-1343(b3)) that participation by probationers in thisresidential programmust be basedon screening and assessmentthat indicate chemical dependency. Representatives from thestate-funded Treatment Accountability for Safer Communities(TASC) programs complete the assessment in the communityto determine appropriateness for treatment. This facility offersa28-dayprogramanda90-dayprogram.Thereare100treatmentslots in the 28-day program, a facilitated cognitive-behavioralintervention, designed to impact criminal thinking in relationto substance abuse behavior in the community.

The 90-day program has two therapeutic communitiesin separate buildings, each with 100 treatment slots (a slotis equivalent to a full-time treatment opportunity for anindividual). The therapeutic community model views drugabuse as a disorder of the whole person. Treatment activitiespromote an understanding of criminal thinking in relation tosubstance abusebehavior andengage theoffender in activitiesthat encourage experiential and social learning. The communityof offenders is the main driving force in bringing aboutchange. In response to an identified need, 10 treatmentslots are designated as “priority” beds. These are availablefor probationers or parolees who are experiencing severesubstance dependence-related problems and are in need of


immediate admission to the 90-day residential treatmentprogram. Priority beds are not for detoxification purposes.

Upon completion of the DART-Cherry program, acomprehensive aftercare plan is developed by the offender’scounselor. The aftercare plan is included in the case filematerial which is returned to the offender’s supervisingprobation/parole officer to ensure continued treatmentfollow-up in the community and the completion of the aftercareplan.

The North Carolina Legislature approved approximately$1.9 million during its 2008 session for a substance abusetreatment program for female probationers and parolees.This will provide women the same treatment services nowavailable to men at DART-Cherry in Goldsboro. Located in arecently vacated women’s prison facility in Black Mountain,the program will have 50 treatment beds. Both 28-day and90-day programs will be available to women on parole orprobation from across the state. The facility should be staffedand ready to receive offenders by the second quarter of 2009.

Current Challenges

Prison Population Growth and Treatment NeedsThe North Carolina prison population has grown at a

steady rate over the past six fiscal years. However, the numberof substance abuse treatment slots has decreased over thesame period (see Figure 1). On June 30, 2001, there were31,899 inmates in North Carolina prisons and 1,898 treatmentslots in substance abuse programsavailable annually.Over thenext six years, the total prison population increased by 6,524,but a total of 408 treatment slots were lost due to budgetreductions.1

In FY 2006-2007, the Department of Correction, Office ofResearch and Planning, conducted an assessment of supplyand demand for long-term substance abuse treatment withinDACDP. The study included the five long-term (180-360days) treatment programs located at four prisons and the twoprivate treatment facilities, analyzing treatment severity and

need for 63,632 peoplewhowere in prison at some point duringthe designated timeframe, and met the analysis criteria. Theresults indicatedthat long-termtreatmentneedexceedsprogramsupply by approximately 286%, as there were nearly threeinmates meeting treatment criteria for each single programslot.5

According to the North Carolina Sentencing and PolicyAdvisory Commission, in conjunction with the Office ofResearch and Planning, the prison population will grow from39,397 in 2008 to 46,801 by 2017, representing a projectionof an additional 7,404 inmates.6Considering current limitations,and in the absence of additional resources, the anticipatedgap between treatment need and treatment availability, asillustrated above, will continue to increase.

Clinical WorkforceIn September 2005, DACDP staff and operations were

directly affected by changes to state law (GS 90-113.40)regarding professional credentialing of clinical staff. Thechanges mandated certification/licensure for all substanceabuse professionals; created a new credential, the CertifiedCriminal JusticeAddictionProfessional (CCJP); andestablishednew clinical supervision requirements for clinical practice.

With the establishment of a clinical development team ofcertified clinical supervisors and trainers, the Division haseffectively addressed the practice standards established inthe legislation. In fact, DACDP is able to provide all clinicalsupervision and most training requirements for credentialingat no cost to the professional staff. However, competition hasincreased over the last five years among state and privateproviders for credentialed substance abuse professionals.Accordingly, it will continue to be a constant challenge forDACDP to remain an attractive employment option, asprofessionals consider work within the prison environment andlimitations on compensationwithin the state personnel system.

Substance abuse treatment providers continue to facechallenges addressing the diverse needs of the offenderpopulation in North Carolina. Budget constraints limit the

Division from keeping pace withthe treatment needs of all of theinmate population, and the needsof female probationers andparolees are only just beginningto be addressed. While greatstrides have been made to meetthe mandates of professionalcredentialing, salaries still fallbehind in comparison with othersubstance abuse providers inNorth Carolina. Current budgetcutbacks have begun to affectall North Carolina state agenciesand the economic outlook doesnot appear to show immediateimprovement.


Figure 1.Cumulative Change in Prison Population and Treatment Slots


In spite of these factors, the Division of Alcoholism andChemicalDependencyProgramshasmadetremendousprogressover the past few years in service delivery by implementing astandard cognitive-behavioral based curriculum, by establishinga certified cadre of counselors receiving training and clinical

supervision, and by dedication to evidence-based practicesin treatment delivery. With expanded programs and morecompetitive salaries, the Division will continue, with dedicationand commitment, to strengthen and expand its substanceabuse treatment to the offender population. NCMJ

REFERENCES

1 Division of Alcoholism and Chemical Dependency Programs.Annual Legislative Report FY 2006-2007, Executive Summary.Raleigh, NC: North Carolina Dept of Correction; 2008.

2 Data Spotlight. Recidivism. Management & TrainingCorporation website. http://www.nicic.org/Library/020435.Accessed November 21, 2008.

3 110th United States Congress, H.R. 1593. Second Chance Act of2007, Chapter 4 (b) Findings. Library of Congress website.http://thomas.loc.gov/cgibin/query/F?c110:5:./temp/~c110TipzKq:e1141. Accessed November 21, 2008.

4 North Carolina Legislative Research Commission. Report to the1987 General Assembly of North Carolina: Inmate SubstanceAbuse Therapy Program. American Libraries Internet Archivewebsite. http://www.archive.org/stream/inmatesubstancea00nort. Accessed November 21, 2008.

5 Office of Research and Planning. North Carolina Department ofCorrection. Statistics Memo, Long-Term Substance AbuseTreatment: Treatment Need Compared to TreatmentAvailability. Raleigh, NC: North Carolina Dept of Correction;2008.

6 North Carolina Department of Correction. Annual StatisticalReport FY 2006-2007. Prison Population Projections. Chapter1D. Raleigh, NC: North Carolina Dept of Correction; 2008.

“It is the most satisfying thing I have ever done as a judge. I feltthe courts did not adequately deal with drug abuse andaddiction.”a

he above statement, made by a North Carolina DrugTreatment Court judge, is typical of the responses shared

by professionals involved in therapeutic courts.Most child welfare workers estimate thatapproximately 70% of all child abuse or neglectis due to one or both parent’s alcohol or otherdrug abuse/addiction.b,1More than one-half of allcriminal cases before the North Carolina courtsinvolve people with alcohol and other drug(AOD) abuse and addiction. In 2008, 202,942drug-related charges were brought before theNorth Carolina Criminal Courts and there were72,867 DWI charges. These numbers do notinclude approximately one million additionalcriminal cases such as assault, breaking andentering, and larceny that were committedunder the influence of drugs and/or alcohol orcommitted to support the offender’s addiction.Two-thirds of all intimate partner abuse involves alcohol, 35%of all violent crime is committed under the influence of alcohol,and two-thirds of all simple assaults involve alcohol.2 Becauseof the correlation between AOD abuse and crime, we mustfind a means of addressing the common cause—addiction—in an effective and cost-efficient manner.

The 1980s saw the explosion of crack cocaine use, andmany courts around the country responded by creating “drugcourts” designed to “fast-track” offenders throughprosecutionand into jail or prison. In 1989, however, a Miami judge anddistrict attorney launched a very different kind of drug court.3

Their hypothesis was that until individuals actually enteredtreatment and became clean and sober, they would continueto abuse drugs and alcohol, continue to break the law, andcontinue to be brought before the court and sent to prison. Thisexperimental court worked to identify nonviolent drug addicts,

get them assessed, get them into treatment, and then keepthem in treatment. Proponents recognized that the problemwas not always getting people into treatment but rather keepingthem in treatment. The judge and the prosecutor designedtheir approach to leverage the strength of the courts in gettingpeople to do things. In ordering people into treatment and

then ordering them to return to the court to report progress(or lack of progress) every twoweeks, the courts sawbehaviorsshift as offenders became more successful at entering andremaining in treatment. From that early beginning, drug courtsand problem-solving courts began to grow exponentially. As ofDecember 2007, there were 2,147 operational treatmentcourts across the nation.3

How are Drug Treatment Courts Different fromRegular Courts?

Drug Treatment Courts (DTC), a form of therapeutic orproblem-solving court, operate on the principle of coercedtreatment through intensive judicial intervention. Studieshave shown that coerced treatment—when an individual isforced into treatment by the courts, an employer, or family—

a Anonymous Drug Treatment Court judge, oral communication, August 2008.b Due to differences in reporting requirements, the exact prevalence of parental AOD abuse/addiction in child maltreatment varies but

practitioners report a high correlation.

“[Drug Treatment Courtswork] to identify nonviolentdrug addicts, get themassessed, get them intotreatment, and then keepthem in treatment.”

Kirstin Frescoln is the manager of the North Carolina Drug Treatment Court within the North Carolina Administrative Office of theCourts, Court Programs Division. She can be reached at kirstin.frescoln (at) aoc.nccourts.org.

Drug Treatment CourtsKirstin Frescoln


T

c The research regarding effectiveness of treatment and time in treatment has progressed through several important studies (Pescor, 1943; Simpsonand Sells, 1983; Hubbard, et al., 1989). Clients in the national DrugAbuse TreatmentOutcome Study reported significant overall improvementsin drug use and relatedmeasures during a 12-month follow-up period. A quasi-experimental designwas used to examine the relationship oftreatment durationwith outcomes in each of the threemajormodalities represented. Client subsampleswith longer retention in long-termresidential programs and in outpatientmethadone treatment had significantly better outcomes than thosewith shorter lengths of stay.

4

d Adult Drug Treatment Court members include a district or superior court judge, an assistant district attorney, a specialized probation officer, aTASC provider, a DTC coordinator, and a treatment professional. Family DTCmembers include a juvenile court judge, a Department of SocialServices county attorney, a parent attorney, a guardian ad litem, Department of Social Services staff, an FDTC coordinator and treatmentprofessionals. Juvenile DTCmembers include a juvenile court judge, an assistant district attorney, a defense attorney, a juvenile court counselor,a JDTC coordinator, and a treatment professional. Any of these teamsmay include professionals from other agencies or departments.

e NC Stat §7A-790 et seq.f Adult DTCs are located in Avery, Buncombe, Brunswick, Burke, Carteret, Caswell, Catawba, Craven, Cumberland, Durham, Forsyth,

Guilford, McDowell, Mecklenburg, New Hanover, Person, Pitt, Orange, Randolph, Rutherford, andWake counties.g JDTCs are located in Durham, Forsyth, Mecklenburg, Rowan, andWake counties.h FDTCs are located in Buncombe, Chatham, Cumberland, Durham, Gaston, Halifax, Lenoir, Mecklenburg, Orange, Robeson, Union, and

Wayne counties.i Adult Criminal and Family DTC participants must have a diagnosis of AOD dependence. Juvenile DTC participants must have a diagnosis

of abuse as indicated by the DSM-IV-TR.

is as effective, and arguably more effective, than enteringtreatment voluntarily.c,4 Not only are DTCs more effective atgetting individuals to begin treatment, they are much moreeffective at keeping individuals actively engaged in treatment.5

Research has demonstrated that the longer an individualremains actively engaged in treatment, the more likely thatindividual is to attain andmaintain sobriety.4 Three months intreatment is a minimum length of stay with one year or morerecommended to produce truly effective results.4

Drug treatment courts represent the coordinated effortsof the judiciary, prosecution, defense bar, probation, lawenforcement, treatment, mental health, social services, andchild protection services to actively and forcefully interveneand break the cycle of substance abuse, addiction, and crime.d

As an alternative to less intensive interventions, drug treatmentcourts quickly identify substance abusing offenders and placethemunder strict courtmonitoringandcommunity supervision,coupled with effective, long-term treatment services. In thisblending of systems, the drug court participant undergoesan intensive regime of substance abuse and mental healthtreatment, case management, drug testing, and probationsupervision while reporting to regularly scheduled statushearings before a judge who has specialized expertise in thedrug court model. In addition, drug courts often facilitate jobskills training, family or group counseling, parenting classes,and many other life-skill enhancement services.

TheNorth CarolinaDrug Treatment Courtswere establishedby statute in 1995 to enhance and monitor the delivery oftreatment services to chemically dependent adult offenderswhile holding those offenders rigorously accountable forcomplying with their court-ordered treatment plans.e In 2001,the General Assembly formally authorized expansion of theDTCs to include substance abusing juvenile offenders andchemically dependent parents of neglected or abused children.e

Today, there are 43 operational adult,f juvenile (JDTC),g andfamily (FDTC)h drug treatment courts in North Carolina.

The goal of the DTC is to break the cycle of addiction thatgives rise to repeated law-breaking episodes. By enhancing

the likelihood that the drug-driven offender will remain drugand crime free, as well as socially responsible, the DTC seeksto reduce justice system, health system, and other societal costsassociatedwith continuing drug use and criminal involvement.

The objectives of North Carolina’s Drug Treatment Courts are:1. To reduce alcoholism and other drug dependencies

among adult and juvenile offenders and defendants andamong respondents in juvenile petitions for abuse,neglect, or both.

2. To reduce criminal and delinquent recidivism and theincidence of child abuse and neglect.

3. To reduce the alcohol-related and other drug-relatedcourt workload.

4. To increase the personal, familial, and societalaccountability of adult defendants, juvenile offenders, andrespondents in juvenilepetitions for abuse, neglect, orboth.

5. To promote effective interaction and use of resourcesamong criminal and juvenile justice personnel, childprotective services personnel, and community agencies.

North Carolina’s drug treatment courts specifically targethigh-need, high-risk individuals. Drug treatment courts are anintensive community-based intervention. Research indicatesthat it is important to effectively target the level of need tothe level of the intervention being provided.6 High-needindividuals are those who have been clinically assessed asaddicted to drugs and/or alcohol as indicated by criteriadescribed in the DSM-IV-TR.i High-risk means that theindividual has ahigh likelihoodof reoffending.7 In the caseof thehighly-invasive and resource-intensive drug treatment courts, itis vital to admit only those high-need, high-risk individualswho would benefit from the intervention.

Success Rates

Drug treatment courts are making an impact in NorthCarolinacommunities.Across the threecourt types,participants


remained actively engaged in the court, treatment, andsupervision for an average of 287 days during fiscal year (FY)2007-2008.j In the sameperiod, 38%of adult DTCparticipants,49% of juvenile DTC participants, and 33% of family DTCparticipants successfully completed the program.j Of thoseparents who successfully completed the FDTC in FY 2007-2008, 89% regained custody of their children. In adult DTCs,42%were employedwhile in the court.8TheMay 2008NorthCarolina Sentencing and Policy Advisory Commission reporton recidivism, found that, three years after entering DTC, only29.4%of theDTCparticipants (completed and non-completed)were reincarcerated as compared to 45.2% of all intermediatepunishment offenders.k,7 The rearrest recidivism rates foundin the study are within the expected range—lower than theintermediate offender rate and higher than the communityoffender rate.

Shared Responsibility and Shared Success

The growth of North Carolina’s treatment courts has beenmade possible through the shared commitment and efforts ofstate and local stakeholders. At the state level, the NorthCarolina Department of Correction, Division of CommunityCorrections (DCC); the North Carolina Department of HealthandHumanServices,DivisionofMentalHealth,DevelopmentalDisabilities, and SubstanceAbuse Services (DMHDDSAS); andDivision of Social Services (DSS) Child Welfare, have joinedwith the North Carolina Administrative Office of the Courts(AOC) to develop, implement, and fund the operation of thespecialty courts. State and local memoranda of understandinghave established roles and responsibilities for each of thestate agencies and local DTC team members.8 The DCC hasmade a commitment to place specially-trained probationofficers with smaller case loads on each DTC team. TheDMHDDSAS has lobbied for and received additional targetedtreatment funds for adult DTC participants. The Departmentof Juvenile Justice and local Departments of Social Serviceshave each made commitments to dedicate specially-trainedstaff with reducedcase loads to theDTCteam.TheAOCfundsadedicated court coordinator, judge, assistant district attorney,guardian ad litem staff, and indigent defense services inaddition to the technical assistance and training provided bythe AOC state DTC staff.

Just as local DTC teams require a commitment to sharedresponsibility and shared resources, state-level stakeholdershave agreed to joint accountability and have committedadditional resources. Just as the local stakeholders shareequal claim to the success of DTC graduates, state-level


j Information from preliminary FY 2007-2008 DTC outcome data based upon information included in the NC DTCMIS (Drug TreatmentCourt Management Information System).

k An intermediate punishment requires a period of supervised probationwith at least one of the following conditions: special probation, assignmentto a residential treatment program, house arrest with electronic monitoring, intensive probation, assignment to a day reporting center, andassignment to a drug treatment court program. Generally, offenders who have a significant prior record and commit Class H or I felonies andoffenders who have little or no prior record and commit more serious non-violent feloniesmay receive an intermediate punishment.

”My Life Was a Wreck...Six years ago, I started something that will never befinished. From the very first time I took a drink and used adrug, I engaged myself with addiction. I firmly believethat this is a disease and an incurable one because I haveseen victimswithmyowneyes.When someone is involvedin active addiction, they have no other reason for existingthan to get drunk or high. This is my definition becausethis describes my own experience. I will be fighting myaddictions for the rest of my life and that is okay byme. Itis a much better option to fight than to give in.

I was a drug dealer and on more frequent occasions auser of many types of drugs. My life was a wreck. I neverwent to classes, my health was in a constant state ofdecline, and my only responsibilities were to drink, use,and sell. I lost the trust of everyone around me because Iwas leading a double and sometimes triple life. February11, 2004 was the best and worst day of my life. I lost mybrand new car, all of my money, and was charged withtwo felonies. But everything I had been doing to myselfwas going to come to a halt very soon. The DrugTreatment Court Program was described to me as analternative to prison, so I took it thinking I would be ableto stay out of prison and jail and keep selling drugs. I wasdead wrong. In the beginning, I did most of the things Iwas supposed to do except for the main thing: I neverstopped using. After numerous failed drug screens andtwo trips to jail, I was carted away to the Caldwell Houseresidential home in Lenoir, North Carolina. I was court-ordered to remain in this halfway house for one year. I hadbeen thrust into a situation where I was surrounded byalcoholics and drug addicts with a lot of pain in their eyesand all kinds of horrible stories. It took a little time, but Isoon realized that I was one of these people and that Ineeded help. The year flew by, and I made many friends,some of whom I had to watch relapse and be kicked out.

I have now graduated from Drug Treatment Court andhave over 600 days of sobriety. I am back in school andneed only one more semester to graduate from theUniversity of North Carolina at Chapel Hill. My life ismore than worth living; it is worth enjoying. I have gainedback the trust of the peoplewho loveme, and I havemanypeople in my life that care about me. I am appreciative tothe Drug Court Team for everything they have done forme, but most especially, for believing in me.”

—North Carolina Adult Drug Treatment Court Graduate


REFERENCES

1 Young NK, Boles SM, Otero C. Parental substance use disordersand child maltreatment: overlap, gaps, and opportunities. ChildMaltreat. 2007;12(2):137-149.

2 Greenfeld LA. Alcohol and Crime: An Analysis of National Data onthe Prevalence of Alcohol Involvement in Crime.Washington, DC:Bureau of Justice Statistics; 1998.

3 Huddleston CW, Marlowe DB, Casebolt R. Painting the CurrentPicture: A National Report Card on the Drug Courts and OtherProblem Solving Court Programs in the United States. Vol. II,Number 1.Washington, DC: National Drug Court Institute,Bureau of Justice Assistance, Office of Justice Programs, USDept of Justice; 2008.

4 Simpson DD, Joe GW, Brown BS. Treatment retention andfollow-up outcomes in the Drug Abuse Treatment OutcomeStudy (DATOS). Psychol Addict Behav. 1997;11(4):294-307.

5 Satel S. Drug Treatment: The Case for Coercion.Washington, DC:American Enterprise Institute Press; 1999.

6 Lowenkamp CT, Latessa EJ, Holsinger AM. The risk principle inaction: what have we learned from 13,676 offenders and 97correctional programs? Crime Delinq. 2006;52(1):77-93.

7 Calhoun K, Flinchum T, Katzenelson S, Etheridge V, Hevener G,Moore-Gurrera M; North Carolina Sentencing and Policy andAdvisory Committee. Correctional Program Evaluation: OffendersPlaced on Probation or Released from Prison in Fiscal Year2003/04. http://www.nccourts.org/Courts/CRS/Councils/spac/Documents/recidivismreport_2008.pdf.Accessed January 13, 2009.

8 Annual Report on North Carolina’s Drug Treatment Courts. Raleigh,NC: Administrative Office of the Courts; 2009.

9 Bhati AS, Roman JK, Chalfin A. To Treat or Not to Treat: Evidenceon the Prospects of Expanding Treatment to Drug-InvolvedOffenders.Washington, DC: Justice Policy Center, The UrbanInstitute; 2008.

stakeholders are able to point to drug treatment courts as aninnovative and successful example of high-level collaboration.Working together not only improves outcomes for the DTCparticipants but also improves the practice and increases jobsatisfaction for the DTC team members. As one local DSSstaff person said, “It is so easy to track what is going on withclients involved in DTC, easy to write a case plan, and easy tobe consistent.” An assistant district attorney assigned to aDTC said of hisworkwith the courts, “I enjoy preventing furthercrimes from happening.” A probation officer working withcourts said she was involved because, “knowing you canmakea difference while having the ability to impose immediateconsequences and having teeth in what you do improvesoutcomes.”

Since alcohol and other drugs are involved in a significantproportion of crime in North Carolina and traditional criminaljustice systems are limited in their ability to address thesechronic problems, we must respond more effectively.One in every 100 Americans is currently incarcerated.Disproportionately, one out of every 15 African Americanmen and one out of every 36 Latinomen are now behind bars.Despite the need these numbers create, drug treatment courtsnationally serve only 5% of the adult offender populationestimated to be in need of treatment court services. NorthCarolina DTCs perform a little better, serving about one-third

of appropriate intermediate-level offenders but serve anexceptionally small portion of parent respondents who couldbenefit from the specialized courts. Drug treatment courtsoffer a combination of intensive judicial oversight, intensivetreatment, intensive probation supervision, and frequent drugtesting. North Carolina’s operational drug treatment courtsmust expand to better meet the needs of their communities,and we must increase availability of drug treatment courtsacross the state to provide equal access.9 Research has shownthe effectiveness of coerced and evidence-based treatment.North Carolina has an opportunity, through drug treatmentcourts, to positively affect the lives of those addicted to alcoholand other drugs and the lives of their family members andchildren. We must embrace the challenge and meet thestate’s need. NCMJ

For more information on North Carolina Drug Treatment courtsvisit http://www.nccourts.org/Citizens/CPrograms/DTC.

Acknowledgements: The author wishes to acknowledge thefollowing individuals for their assistance in preparation of thisarticle: Judge James E. Ragan III, JD, North Carolina DrugTreatment Court state advisory committee chair; Gregg Stahl,North Carolina Administrative Office of the Courts senior deputydirector; and Sandy Pearce, court programs administrator.

he North Carolina Division of Community Correctionshas undergone a decade of change in achieving its

mission to “Protect society by applying appropriate controlover the offender while coordinating community resourcesthat enables those under our supervision the opportunity tochange their behavior, support their family, pay restitution andmake reparation to their victims, and to become productivelaw abiding citizens.”

In addition to our many initiatives and partnerships thataddress the risks and meet the needs of an ever-changingoffender population,wehavereached deep within ourprofession to overhaul ourown 65 year-old probationand parole system. Thephilosophy and focus of thisDivision has changed frombeing solely on the offenderto a focuson the community,thevictim,andtheoffenderaswell. In order to be successfulat impactingpositive change,we must provide theopportunity for change forthe offender. Increasedtreatment resources, jobskills training opportunities, and support groups are necessarycomponents of the success model. We have shifted from aone-on-one focus between the probation officer and theoffender to a team supervision approach including probationofficers, treatment providers, law enforcement, families, andthe community as awhole. A balance of control and treatmentis amust for community corrections to be successful in reducingrepeat or future offenses and addressing relapse.

TheDivision of Community Corrections is one of themajoroperating armsof theNorthCarolinaDepartment ofCorrectionand is chargedwith the responsibility of providing supervisionwithin our community of offenderswhoare placedon supervisedprobation or unsupervised probation with community serviceby the courts or who receive post release supervision orparole. The offender population includes those convicted of

felonies, misdemeanors, and DWI offenses. Currently theDivision supervises nearly 128,000 offenders across ourstate, which is a challenging responsibility. To put it intoperspective, if all of the offenders were in one location, therewould be only five cities and 20 counties in our state with alarger population.

During fiscal year 2007–2008, over 72,000 offenders wereadmitted to supervisionwith the Division. For thosewith felonyoffenses, over 37% had committed a drug-related offense. Inthemisdemeanor categories, 22%wereDWIoffenses and 15%

were drug-related. In mostother offense categories,substance abuse is often abehavioral issue for theoffender. TheNorthCarolinaDepartment of Correctionestimates indicate thatover 60% of our offenderpopulation has some formof a substance abuse issueand need for services.

Currently the Divisionworks closely with theDepartment of Healthand Human Services,Division of Mental Health,

Developmental Disabilities, and Substance Abuse Servicesthrough a memorandum of agreement following an OffenderManagement Model. Part of the model requires offenders tobe sent to the local Treatment Alternatives for SaferCommunities (TASC) office for substance abuse assessmentsand placements. TASC provides a bridge between our criminaljustice system agency and community-based treatmentproviders through coordination and oversight of services.TASC assesses and refers offenders to appropriate serviceproviders and treatmentwhile theDivision’s probation officersfocus on supervision within the community and follow-upwith the provider and TASC to determine progress withintreatment. The Division is committed to the principles andpractices of the Offender Management Model and hasestablished standard operating procedures to support a better

Substance Abuse Services and Issues inCommunity Offender SupervisionRobert Lee Guy; Timothy Moose; Catherine Smith

Robert LeeGuy is thedirector of theNorthCarolinaDivisionofCommunityCorrections.Hemaybe reachedat robertleeguy (at) gmail.com.

Timothy Moose is special assistant to the director of the North Carolina Division of Community Corrections.

Catherine Smith is the administrative officer to the director of the North Carolina Division of Community Corrections.

“...estimates indicatethat over 60% of ouroffender populationhas some form of asubstance abuse issueand need for services.”

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understanding of this process. The Offender ManagementModel hasbecome thecentral themeof community correctionsacross the state.

Several more specialized areas also exist. Offenderssentencedwithin the intermediate grid of structured sentencingwho, in theory, pose a higher risk,may be required to completean intermediate sanction such as residential treatment, a dayreporting center, or a drug treatment court program. All ofthese sanctions include strict supervision with treatment andhave proven to be successful in reducing the risk of reoffending.There are only 21 day reporting centersa and 19 drug treatmentcourts operating in the state, and there are a limited number ofresidential treatment beds available. There are 130 residentialtreatment beds available through the department-operatedDrug Alcohol Recovery Treatment (DART) program, as wellas an additional limited amount that are provided through afew private nonprofit programs.

Themajority of treatment services for offenders are providedon an outpatient basis at the local level, including thosereceived in a drug treatment court or day reporting center.The Division’s Criminal Justice Partnership Program, whichprovides funding for the day reporting centers, also providesfunding for local satellite substance abuse programs andresource centers, programswhich provide a one stop locationfor the outpatient providers to reach the offender population.The partnership program is one of the leading providers offunding for treatment services for offenders, but it has only$9million in funds to reach this large and growing population.

With an ever-growing offender population, substanceabuse services targeted to the offender population have beenunable to meet the needs throughout the state; this hascreated a growing service gap. Particularly in many ruralcounties, the criminal justice partnership-funded programsare the only option to directly reach the offender population.

Offenders, because of their conviction and past behavior,have shown the need for help, yet they are often overlooked inthe face of many competing priorities. Consequently, since itsinception in 1995, the criminal justice partnership has notreceived the funding growth to keep up with the growth in theoffender population or for the cost increases associated withservices. Funding for services has remained static. On April 1,2008 a report was provided to the legislature on the criminaljustice partnership program as part of the legislative reviewfor continued funding. The report provided detail on how theprogram was able to reduce the risk of re-offense by 62% foroffenders who complete one of the partnership programs.The report included a promising assessment of what theDivision’s supervision combined with treatment can do tochange offender behavior towards the positive.

In order to continue the progress illustrated by thepartnership report, a greater focus on the combination ofsupervision and treatment for offenders will be necessary.While successful, all partnership programs combined reachless than 7,000 in the offender population each year. Whilenot all offenders are in need of this type of intense supervisionand treatment, we must strive to reach all offenders in needwith the appropriate level of service in order to reduce riskand reoffending behaviors.

The Division of Community Corrections’ hardworking,dedicated probation officers are a vital key to changingbehavior, but many other components are necessary in orderto be successful. The assessment of offenders’ risk and needsis a top priority of the Division, a project that began in 2008.However, if the Division and its community partners are notprovided the treatment resources and other wrap-aroundservices necessary to address the risk and needs identifiedthen our goal to reduce reoffending may prove to be doomedfrom the beginning. NCMJ

a Reporting centers are restrictive, treatment-oriented facilities where substance abuse services, employment services, and educationalservices are provided on-site with strict requirements for offender attendance and accountability.


ike millions of others, I watched with intense interest thepre-election news coverage, including the accusations

regardingACORN. I was particularly struck by the implicationsthat ACORN had hired “homeless people, convicted felons,recovering alcoholics, and drug addicts—people who will doanything for money,” at least according to CNN, CBS, NBC,ABC, and FOX news. Imagine the scandal if ACORN hadstooped so low as to hire people with diabetes or asthma. Itwas quite sobering to realize howmuch education there is leftto do for the general public regarding addictivediseases. Unfortunately, that same ignoranceexists in the medical profession as well.

Alcoholism and Drug Addiction arePrimary Illnesses

About 10-12% of the United States adultpopulation has an addiction. This means that ifyou, as a physician, treat 1,000patients, at least100 are addicted. Do you know who they are?Probably not. Not knowing who they are meanstheyareundiagnosedanduntreated.Thealcoholicor drug addict’s self-assessment can make thediagnosis difficult. Alcoholics and addicts operateunder a delusion that they are not addicted. Thisdelusion is different from a lie. Alcoholics andaddicts can describe their drinking or drug usein awaynot even remotely resembling reality, andyet theycanpassa lie-detector test.Asaphysicianit is important that we are able to screen for addiction withevery patient. It really is not that time-consuming. How manydays in the pastmonth have you consumed an alcoholic beverage?How many ounces of alcohol do you consume per drinkingepisode? Have you ever blacked out? And there are the CAGEquestionsa aswell.Have you ever felt you should cut down on yourdrinking? Have people annoyed you by criticizing your drinking?Have you ever felt bad or guilty about your drinking? Have youever had a drink first thing in themorning to steady your nerves or

get rid of a hangover? It is also a good idea to ask the spouse orsignificant other about the patient’s alcohol use. Your efforts intreating other medical conditions will likely lead to greatfrustration and poor outcome if the addiction is undiagnosed.Patients with hypertension that is harder to control in themorning could be experiencing alcoholic withdrawal. Patientswith chronic complaints of awakening in the early morninghours could be experiencing alcohol withdrawal. Psychiatricpatients who complain of chronic anxiety during the day,

punctuated with panic in the morning, could be experiencingalcoholwithdrawal. Alcoholic patients present to their physicianscomplaining of depression, anxiety, and sleep disturbance.Unfortunately, these symptoms do not respond to traditionaltreatment if the drinking continues.

At Fellowship Hall,b I monitor patients’ depressive symptomsby using Beck Depression Inventories. About 95% of patientshave scores greater than 30 at admission, indicating severedepression. Byday21, only about4%continue tohaveelevation

The Physician’s Role in Treating Addiction asa Diagnosable and Treatable IllnessDewayne Book, MD

Dewayne Book, MD, is the medical director for Fellowship Hall, an alcohol and drug addiction treatment facility in Greensboro, NorthCarolina. He can be reached at dewayneb (at) fellowshiphall.com.

“As a physician it is importantthat we are able to screen foraddiction with every patient…Your efforts in treating othermedical conditions will likelylead to great frustrationand poor outcome if theaddiction is undiagnosed.”

a The CAGE is a very brief screening tool that asks four direct questions. Any positive answer warrants investigation. The more answersendorsed the more likely that the patient is having problems with alcohol.

b Fellowship Hall, founded in 1971, is a 60-bed private nonprofit alcoholism and drug treatment facility providing medical detoxification and12-step based treatment to adult men and women.

L


in their BeckDepression Inventory scores. This iswhat is knownas substance-induced mood disorder. The DSM-IV (Diagnosticand StatisticalManual ofMental Disorders-IV) clearly states foreach diagnosis that the diagnosis should not be made if thesymptoms can better be explained by a medical disorder or asubstance use disorder. For example, cocaine-induced maniafollowed by alcohol-induced depression does not constitutebipolar disorder. More importantly, neither antidepressantsnor mood stabilizers change the use patterns of alcoholics oraddicts. There are some patients that are alcoholics who havecomorbid psychiatric disorders. Unfortunately, the substanceuse must stop before symptoms of the psychiatric disorderwill remit, even if the psychiatric intervention is appropriate.Regardless of which came first, the substance use must be inremission before the psychiatric symptoms can effectively beaddressed. The same is true for conditions such as diabetes,hypertension, and hypothyroidism. Make addiction your first“rule out” in every patient.

Alcoholism is aprimary illness, not the result of anunderlyingcondition. There are structural differences in the brain in peoplewith addictions prior to introduction of the addictive chemical,and certainly after repeated exposure. In addition, some peoplehave a predisposition to addiction. Naïve drinkers with a familyhistoryofalcoholismexperiencegreatereuphoriawhenexposedto alcohol as compared to those without a family history. Thispartly explains why non-alcoholics cannot understand thedrinking patterns of alcoholics. It is these brain differences thatdrive the compulsion to use the chemical despite negativeconsequences. This is the hallmark of addiction: continued usedespite negative consequences. A person who is addictedmay have, for example, multiple citations for driving whileintoxicated (DWIs) or repeated elevated liver enzymesdespite warnings from his physician about the adverse healthconsequences.Drinkerswhocan stopwill stopwhenconfrontedwith negative consequences. Alcoholics continue to drinkdespite these consequences and develop sophisticatedrationalizations to continue.

Alcoholism and Drug Addiction areDiagnosable and Treatable Illnesses

The way physicians are trained to recognize and treat thispopulation is fraught with problems. Asmedical students andresidents, our exposure to alcoholics and addicts is generallyin the emergency department (ED) with the patient beinghighly intoxicated and often belligerent. If you assess thispatient appropriately, which rarely happens, and make anappropriate disposition, which also rarely happens, and thepatient is compliant with that disposition, which, again, rarelyhappens, you will never see that patient in the ED again.Alcoholics are less likely than people with diabetes or asthmato re-present to the ED after appropriate treatment. If any ofthe three “ifs” fails, the patient will re-present. This may leadto the care provider developing the belief that alcoholics andaddicts never get better. The reality, however, is alcoholics

and addicts respond to appropriate treatment with greatersuccess than most (other chronic illnesses).

Addiction is a chronic and often relapsing illness. Careproviders see a relapse as a treatment failure. Imagine adiabetic patient who for six years closely follows his diabetictreatment plan of appropriate diet, exercise, and insulin. Forsix years his blood glucose is normal. Then for some reasonthe patient stops taking insulin and winds up in a diabeticketoacidosis (DKA). The physician will attempt to reconvincethe patient to be compliant with the insulin and may use thesix-year success period as evidence that insulin is effective.The opposite is true with alcoholism. The alcoholic faithfullyfollows her 12-step recovery program for six years and thenstops. Soon after, her Alcoholics Anonymous (AA) meetingattendance stops, and the alcoholic begins drinking again.Care providers use this as a demonstration that treatmentdoesn’t work. In both instances, treatment worked as long asthe patient was compliant.

Suppose tomorrow you see a patient in your practice withmildly elevated liver enzymes, and you talk to the patientabout his drinking. Frequently, alcoholics are told to “cut downon your drinking, and I’ll see you in three months,” withoutbeing told how to address their excessive use of alcohol.Suppose you see a patient with a blood sugar of 400, and astheir physician you tell them to lower their blood sugar andyou’ll see them in three months. Generally physicians willprescribe appropriate anti-hyperglycemic medications andrefer the patient to a specialist and a nutritionist for addedsupport.

Very few physicians understand addiction and even lessknow how to treat it. A few years back, during grand roundsfor a familymedicine department, an attending physicianmadethis statement: “I know what the symptoms of alcoholism are,what the abnormal lab values are, and can diagnose alcoholdependence. But I never do, because I don’t know what to doabout it.” Imagine if I said, “I know the abnormal EKG findingfor an acute myocardial infarction (MI) and the patient’ssymptoms, but I never diagnose acute MI, because I don’tknowwhat to do about it.” To do nothing is theworst thing youcan do.

For the alcoholic, the key to recovery is abstinence. I willgenerally contract a patient into an abstinence-based plan thatincludes AA, outpatient therapy, inpatient treatment, or otherappropriate services. If the patient drinks again, I recommenda more intensive level of care—generally inpatient treatment.It is important that the family be informed of this agreementand be willing to follow through with the noncompliancecontingency plan that was developed at the initial contractsession. The patient’s inability to abstain is seen not as failurebut merely as data that their disease is too far progressed totreat at an outpatient level of care. The exception is a patientwho cannot safely stop drinking. Delirium tremens has a 30%mortality rate. For many patients, detox is not a do-it-at-homeproject. I have seen countless patients who have been given abenzodiazepine to self-detox and present now addicted to both


the benzodiazepine andalcohol. Aswe know, a combination ofalcohol and benzodiazepine has the potential to be a lethalcombination. The American Society of Addiction Medicine(ASAM) has delineated levels of care from detox to outpa-tient. Each patient is assessed on a multidimensional modeland placed in the appropriate level of care. Patients can moveup or down these levels of care depending on progress or lackthereof. Treatment is seen as a process rather than an event.ASAM’s four levels of care for alcohol and other drug (AOD)abuse treatment are described in Patient Placement Criteria forthe Treatment of Psychoactive Substance Use Disorders.1 Theyare presented in Table 1, with brief descriptions of settingsand services.

Recently I admitted a patient who had been prescribedacamprosate. He was taking this medication as prescribed:one 333mg tablet each morning with the plan to titrate

the medication up to recommended dose. Acamprosate isprescribed at 666mg three times eachday. There is no titrationup or down. This was not the glaring error, however. The errorwas that the patient had been prescribed the medication asthe sole intervention into his alcoholism. There are threemedications that have been shown to be efficacious in thetreatment of alcoholism. Naltrexone, acamprosate, anddisulfiram. None, however, have ever been shown to have anyefficacy unless part of a comprehensive treatment program.

Everyday in your practice you will encounter alcoholismand drug addiction. Don’t be fooled by the presentation of theconsequences of the illness; if you only treat the consequenceyou will miss the cause. Alcoholism and drug addiction arediagnosable and treatable illnesses that warrant our attentionand intervention. Perhaps the only wrong intervention is to donothing. NCMJ


An organized nonresidential treatment service or an office practice with designatedaddiction professionals and clinicians providing professionally directed AOD treatment.This treatment occurs in regularly scheduled sessions usually totaling fewer than ninecontact hours per week. Examples include weekly or twice-weekly individual therapy,weekly group therapy, or a combination of the two in association with participation inself-help groups.

A planned and organized service in which addiction professionals and clinicians provideseveral AOD treatment service components to clients. Treatment consists of regularlyscheduled sessions within a structured program, with a minimum of nine treatmenthours per week. Examples include day or evening programs in which patients attend afull spectrum of treatment programming but live at home or in special residences.

An organized service conducted by addiction professionals and clinicians who provide aplanned regimen of around-the-clock professionally directed evaluation, care, andtreatment in an inpatient setting. This level of care includes 24-hour observation,monitoring, and treatment. Amultidisciplinary staff functions under medical supervision.An example is a program with 24-hour nursing care under the direction of physicians.

An organized service in which addiction professionals and clinicians provide a plannedregimen of 24-hour medically directed evaluation, care, and treatment in an acute careinpatient setting. Patients generally have severe withdrawal or medical, emotional, orbehavioral problems that require primary medical and nursing services.

Table 1.American Society of Addiction Medicine Adult Placement Criteria forthe Treatment of Psychoactive Substance Abuse

Level IOutpatient treatment

Level IIIntensive outpatienttreatment (includingpartial hospitalization)

Level IIIMedically monitoredintensive inpatienttreatment

Level IVMedically managedintensive inpatienttreatment

REFERENCE

1 Hoffman NG, Mee-Lee D, Halikas JA. Patient Placement Criteriafor the Treatment of Psychoactive Substance Use Disorders. ChevyChase, MD: American Society of Addiction Medicine; 1991.


ubstance abuse counseling has evolved significantly sinceits earliest documented beginnings with the founding of

AlcoholicsAnonymous in themid-1930s.Unlikemost careers inthehealth care field, substanceabusecounseling is aprofessionin which a significant number of professionals have themselvesbeen recipients of substance abuse services. This uniquecharacteristic of the field has created specific challenges aswell as opportunities.

One obstacle often associated with the field of substanceabuse counseling is the rapid turnover rates of counselors.Although turnover is experienced in all professions, there is aconsequential “bleeding out” of collectivewisdom and expertise as counselorsleave the substance abuse workforce.As counselors strive to excel in theirchosen career and are committed tohelping individuals in active addictionand recovery, they themselves face thestigma that is often associated withsubstance abuse. Substance abusecounselors have been forced to play aleading role as advocates for recognitionas providers of clinical services.

The field has grown stronger as aunited voice as it has collaborated toface these challenges. Codes of conducthave been developed to encouragebetter ethical practices and to addressboundary issues that sometimes arisefor substance abuse professionals.Credentialing boards and certifications have been establishedto promote education and competency standards in order tosafeguard the public from unqualified counselors and to solidifysubstance abuse counseling as a valid profession. The NorthCarolina Substance Abuse Professional Practice Board(NCSAPPB) has been established as the state’s credentialingboard with the International Certification and ReciprocityConsortium, Inc. (IC&RC) as its parent organization.

Incorporated in 1981andcurrentlyheadquartered inHarrisburg,PA, IC&RC is a nonprofit voluntary membership organizationcomprised of certifying agencies charged with credentialing

or licensing alcohol and other drug abuse counselors, clinicalsupervisors, prevention specialists, co-occurring professionals,and criminal justice professionals.1The IC&RCand itsmembersarecommittedtoprotecting thepublic throughtheestablishmentof quality, competency-based certification programs forprofessionals engaged in the prevention and treatment ofaddictions and related problems. IC&RC also promotes theestablishment and recognitionofminimumstandards toprovidereciprocity for certified professionals. The North CarolinaSubstanceAbuse Professional Practice Board is one of the fivelargest IC&RC member boards.

TheNorthCarolina SubstanceAbuse Professional PracticeBoard, originally chartered in August of 1984, has evolvedover the past two and a half decades. The Board was grantedstatutory authority in 1994 and its legislative authorizationchanged from a Title Act to a Practice Act in September of2005.2 There have been many catalysts for change over thepast 14 years. However, it was the Board’s reaction toworkforcedevelopment demands that resulted in the introduction oflegislation in the 2008 legislative session.

The Board requested legislation that would streamline theapplication process for both Certified Substance Abuse

Adequacy of the Substance Abuse WorkforceAnna Misenheimer

AnnaMisenheimer is the executive director of the North Carolina Substance Abuse Professional Practice Board (NCSAPPB). She canbe reached at anna (at) recanc.com.

“Unlike most careers in thehealth care field, substanceabuse counseling is a professionin which a significant number ofprofessionals have themselvesbeen recipients of substance

abuse services.”

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a A person certified by the Board to practice under the supervision of a practice supervisor as a substance abuse counselor in accordancewith the provisions of this Article.

b A person licensed by the Board to practice as a clinical addictions specialist in accordance with the provisions of this Chapter.c NC General Statute § 90-113-30.d A person who completes all requirements to be registered with the Board and is supervised by a certified clinical supervisor or clinical

supervisor intern.e A registrant who successfully completes 300 hours of Board-approved supervised practical training in pursuit of licensure as a clinical

addictions specialist.f A person certified by the Board to practice as a clinical supervisor in accordance with the provisions of this Article (G.S.90-113.31A).g A person designated by the Board to practice as a clinical supervisor under the supervision of a certified clinical supervisor for a period

not to exceed three years without a showing of good cause in accordance with the provisions of this Article.

Counselors (CSAC)a and Licensed Clinical AddictionsSpecialists (LCAS)b aswell as update terminology in its statute.c

On July 28, 2008, the General Assembly of North Carolinaenacted Senate Bill 2117, Amend SubstanceAbuse ProfessionalsAct. The implications of this recent legislation include anever-growing roster for the credentialing examinations andbroader recognition of qualified substance abuse professionals.

Prior to the passage of NC Senate Bill 2117, substanceabuse counselor applicants were required to take and passtwo examinations—one written and one oral—before beingeligible for credentialing as a CSAC or LCAS. Senate Bill 2117eliminated the oral examination fromcredentialing standards. Asaresult,acounselor is requiredtotakeandpassanewly-compiledwritten exam which includes items that test knowledge oncompetencies that had been covered on the earlier oral exam.Although a counselor must still meet credentialing standardsthat existed prior to the 2008 legislation, the applicationprocess has been significantly streamlined as a result.Counselors who once might have been content with simplyobtaining registrant statusd with the Board (registration isrequired in order to provide substance abuse counselingservices in North Carolina) have been seeking CSAC or LCAScredentialing. In December 2007, the Board administered thewritten exam to 97 counselors while 241 counselors wereregistered for the December 2008 exam. Eighty CSACs and84 LCASs have been credentialed since the Board’s statutewas amended at the end of July 2008.

In addition to the elimination of the oral examination, CSACand LCAS applicants are now being recognized for meetingminimum credentialing standards with the use of updateddefinitions and terminology. A CSAC intern is a registrantwho successfully completes 300 hours of Board-approvedsupervised practical training while the same would qualify aLCAS applicant as a Provisional Licensed Clinical AddictionsSpecialist.e One positive consequence of updating thesedefinitions is that a tiered credentialing process has beenestablished for counselors as theypursueaparticular credential.As a result, employers have begun to recognize and awardcounselors as they progress in the application process. Manyemployers have started to establish deadlines by whichemployees should obtain the intern and provisional statusto ensure job security, some even increasing a counselor’scompensation as one completes credentialing standards andachieves a specific status with the Board.

The tiered structure of registrant to intern/provisional tocredential also motivates counselors to actively pursue his orher credential as additional services can be provided uponmeeting credentialing standards for each separate tier. A primeexample of this would be that LCAS-provisional counselors arenow eligible to bill Medicaid for certain clinical services.3

This ability to seek reimbursement enhances their validity asqualified professionals and increases their marketability inthe health and human services workforce.

Despite the Board’s legislative efforts, perhaps the mostpressing workforce development issue facing the professionand counselors pursuing credentialing is the limited numberof Certified Clinical Supervisors (CCS)f that are available toprovide clinical supervision toCSACand LCASapplicants. Thisis especially true as the volume of CSAC and LCAS applicantscontinues to increase. The problem is further exacerbated inrural countieswhere access to theseCCS supervisors is difficultor, in some cases, impossible.

The Board has worked to help remedy this shortage byproviding a listing of names and contact information on itswebsite of those CCS counselors who are willing to provideclinical supervision to applicants.4 Additionally, the Boardrecognizes CCS applicants that have met certain CCScredentialing standards as Clinical Supervisor Interns (CSI).g

CSIs are eligible to provide clinical supervision to CSAC andLCAS applicants while completing credentialing standards toobtain the Certified Clinical Supervisor credential. As themain difference between a CSI and a CCS is that a CCS hasaccumulated the required two years of experience as asubstance abuse clinical supervisor and taken and passed thewritten exam, the CSI status allows a CCS applicant theopportunity to accumulate the clinical supervision-specificwork experience required before being allowed to sit for theCCS written exam.

The profession has matured greatly as counselors haveunited to create a single, effective voice.With the establishmentof standards enforced by credentialing bodies such as theNorth Carolina Substance Abuse Professional Practice Board,substance abuse professionals are finally receiving deservedrecognition as qualified professionals who render clinicalservices. Although the most pressing issue at this time is theinadequate number of credentialed counselors distributedthroughout North Carolina, this situation improves every dayas more and more credentialed counselors—of all levels—enter the workforce. NCMJ


REFERENCES

1 IC&RC: Public protection through credentialing. IC&RC website.http://www.icrcaoda.org/about.asp. Accessed January 6,2009.

2 The Professional Practice Board. North Carolina SubstanceAbuse Professional Practice Board website.http://www.ncsappb.org/boardsteve/index.htm. AccessedJanuary 6, 2009.

3 North Carolina Department of Insurance. Advisory notice:session law 2008-130 (senate Bill 2117) NC General Statute §58-50-30. North Carolina Substance Abuse ProfessionalPractice Board website. http://www.ncsappb.org/boardbuzzsteve/lcasadvisory.pdf. Accessed January 6, 2009.

4 Supervisors. North Carolina Substance Abuse ProfessionalPractice Board website. http://www.ncsappb.org/supervisorsteve/index.htm. Accessed January 6, 2009.

Partying, dancing, hanging out, your teenagers live in a totally different world

that may include marijuana.Learning to recognize warning signs of marijuana use can help protect your kids.

Office of National Drug Control Policy/Partnership for a Drug-Free America®

t the age of 29 I had to face the stark reality that I was anaddict. I was raised in Durham, North Carolina, where

my father was a professor of sociology at Duke University, andmymother worked in the DukeOffice of Cultural Affairs. After Igraduated from the University of North Carolina at Greensboroin 1986,myaddiction to alcohol anddrugs began to spiral out ofcontrol, and Iwas facing serious legal problems. Since I still hadhealth insurance I was able to go to an inpatient treatmenthospital, then to a superior outpatient treatment program, butI found myself with no safe place to live. Out of desperation Idecided to try an Oxford House; I had heard that these wereplaces where recovery without relapse was the norm. A newOxford House for women had just opened in Raleigh and Idecided to apply. I went to the interview and was accepted.This oneactmayhave savedmy life. Iwas able to livewith otherindividuals in recovery, consult with them on all decisionsaffecting my life, participate in 12-step meetings, and stay aslong as I needed, which in my case was about two years.Today, almost 16 years later, I am still sober.

The first Oxford House was founded in Silver Spring,Maryland, in 1975 when a group of recovering alcoholics anddrug addicts took over the county-run halfway house that wasclosing. The ideawas simple—to provide a safe and supportiveenvironment for individuals recovering from alcoholism anddrug addiction for as long as it took to maintain sobriety. Thehousewas run democratically with elected house officers andregular house meetings. Each house member agreed to payan equal share of house expenses, and members agreed toimmediately expel any member who relapsed. Today thereare more than 1,300 Oxford Houses, including 127 OxfordHouses in North Carolina. The houses today follow the samesystem of operation that was established in the first house.

The concept underlying self-run, self-supported recoveryhouses is the sameas the oneunderlyingAlcoholicsAnonymousand Narcotics Anonymous—addicted individuals can help

themselves by helping each other abstain from alcohol anddrug use one day at a time for the time that is sufficient forsobriety to become comfortable enough to avoid relapse. Thetypical Oxford House has 8–15 residents. When a vacancyoccurs, housemembers interviewprospective candidates andvote onwhether to admit them.Once admitted, a residentmaystay as long as he or she believes necessary if they maintainsobriety and pay their equal share of household expenses—about $100 a week. Some house members stay a fewmonthswhile others stay for years. The length of timeneeded for stablesobriety varies with each individual.

Beginning in 1989, the small network of 13 Oxford Housesin the Washington, DC began expansion throughout thecountry as a result of the Anti-Drug Abuse Act of 1988.a Sinceexpansion began, the National Institute on Drug Addiction(NIDA) and the National Institute on Alcohol Abuse andAlcoholism (NIAAA) have funded extensive research thatshows the success Oxford House has in providing peopleaddicted to drugs and alcohol the opportunity to stay soberwithout relapse. Not only have the studies shown that living inOxford Houses improves primary treatment outcomes forrecovering alcoholics and drug addicts but that they workequally well for individuals with dual diagnoses.b For the last15 years, I have worked for Oxford House, Inc.—the nationalnonprofit umbrella organization for all Oxford Houses—tohelp expand the North Carolina network of Oxford Housesfrom the 22Oxford Houses in the state in 1992, when I movedin, to the 127 that exist today. Someday I hope we will haveenough Oxford Houses in the state to give every recoveringaddict the same opportunity I had to become comfortableenough in recovery to avoid relapse. I will continue to work withthe 941 current residents in North Carolina Oxford Houses tolook for more safe houses where recovery without relapse isthe norm. NCMJ

Oxford Houses and My Road to RecoveryKathleen Gibson

Kathleen Gibson is the chief operating officer for Oxford House, Inc. She can be reached at katgibson (at) nc.rr.com.

A

a 42 USC § 300x-25.b One important study is: Majer JM, Jason LA, Ferrari JR, North CS. Comorbidity among Oxford House residents: a preliminary

outcome study. Addict Behav. 2002;27(5):837–845. Many of the DePaul Studies funded by the NIDA and NIAAA are available athttp://www.oxfordhouse.org/Publications/Evaluation/DePaul and more specific information regarding this study may be found onlineat http://condor.depaul.edu/~ljason/oxford/index.html.



The Mountain Council on Alcohol and Drug Dependence iscommitted to promoting recovery for individuals, families, andcommunities to reduce the harmful impact caused by alcohol anddrug dependency.

n the spring of 2006, a small handful of providers in westernNorthCarolina came togetherwith a vision to return access

to quality substance abuse services to the residents of thispart of the state. The process of mental health reform inNorth Carolina from 2001-2006 had left deep wounds in theprovider community which was reduced by more than half, asevere reduction in prevention services, a loss of most crisisservices, and reductions in all vital resources to reduce andtreat addiction. During the same time period, western NorthCarolina experienced significant increases in hospitalizations,a 16% increase in the county jail population, a 27% increase inthe prison system population, and a 42% increase in chronichomelessness of substance abusers. The founding membershad the strong conviction that solutions could be identifiedand implemented if a coalition could be built that establisheda network of relationships including law enforcement,providers, consumers, business, medical, and vital communitystakeholders. From the volunteer efforts of the few and theirown out-of-pocket contributions, the Mountain Council onAlcohol and Drug Dependence (MCADD) was established. Tothis day, MCADD is fully self-supporting through volunteerismand small community contributions.

The early members of MCADD identified a strategy toaddress the issues and rebuild a continuumof care and coalitionof providers that included provider network building, staffdevelopment, community education and outreach, and directconsultative support to the local law enforcement. The fourprimary members included Tom Britton, director of a localtreatment center and director of the Council; state employeeJim Greer; state activist Bill Cook; and a person who was inrecovery. Together they used their networks to bring together astrong inner core that established subcommittees to carry outMCADD’s mission, including education, website design, eventplanning, strategic planning, and finance. Slowly the Councilhas grown to represent the community with over 100membersincluding law enforcement, social services, 12-step recoverygroups, providers, consumers, and community members.

MCADD has provided nine low-cost training sessions toproviders andcountless no-charge trainings to lawenforcement,community groups, and the state. The Council joined withthe county jail to conduct research that demonstrated thatbetween 60-70% of the locally incarcerated population werediagnosable as chemically dependent,most ofwhomcommittedaddiction-related crimes. The research led to an increase ofcounseling services in the jail and several community projectsto reduce recidivism rates for people strugglingwith addictions.Combinedwith community contributions, the Council has beenawarded funds by the Substance Abuse and Mental HealthServices Administration (SAMHSA) two years in a row to holda “Recovery Rocks the Mountains” event. The event drawsapproximately 400 people and includes a march to the countycourt house. The event is an important step in raising awarenessaround the importance of substance abuse treatment in ourcommunity.With over 23million addicted people in this countrywe cannot ignore the problem, and without partnerships andeducation the Council fears that our people will die and ourincarcerated population will only increase.

Under the direction of a new president, Marie Nemerov,MCADD is in a state of evolution that places it on the crest ofactualizing its full mission through the successful acquisitionof 501c3nonprofit status.Over the past sixmonths theCouncilhas recruited a working board of key community leadersincluding a judge, entrepreneur, state leader, recovering persons,and three providers. The Council can no longer operate solelyon volunteerism and is engaged in a vigorous strategic planningprocess that is focused on the needs of the community today.MCADD’s goal for 2009 is to maintain the work of ourcommittees that provide support and advocacy to consumers,providers, and the community while initiating a capitalcampaign to raise the monies needed to hire staff that canexpand the work of MCADD to all of the Western HighlandsNetwork, setting an example for the rest of the state of whatcan be done with committed people and a lot of sweat equity.

For more information, please visit http://nc-mcadd.org, or contacttheCouncil at 33CoxeAvenue, POBox 1564,Asheville, NC28802;828.398.2263.

The Mountain Council on Alcoholand Drug DependenceTom Britton, MA, LPC, LCAS, CCS, ACS

Tom Britton, MA, LPC, LCAS, CCS, ACS, is the director of ARP/Phoenix, a comprehensive substance abuse services program servingwestern North Carolina. He can be reached at tbritton (at) arp-phoenix.com.

PHILANTHROPYPROFILE

I


Running the NumbersA Periodic Feature to Inform North Carolina Health Care Professionals

about Current Topics in Health Statistics

Penetration of Publicly-Funded Substance AbuseServices in North Carolina

In responses to the 2005-2006 National Survey on Drug Use and Health (NSDUH) 8.5% of North Carolinians18 years of age and older report a dependence on or abuse of illicit drugs and/or alcohol in the past year. Thispercentage rises to 18.8% for 18-25 year old young adults.1 This equates to 583,032 young adults with analcohol or drug use problem. The same survey reports that the treatment gap (those individuals needing, butnot receiving, treatment during the past year) was 33,000 for adolescents 12-17 years of age, 70,000 foryoung adults 18-25 years old, and 89,000 for adults 26 years of age and older. Prescription drug abuse is alsoa significant problem in North Carolina as well as nationally; the NSDUH study revealed that over 260,000North Carolina adults used pain relievers nonmedically.1 The Division of Mental Health, DevelopmentalDisabilities, and Substance Abuse Services is the state agency responsible for the provision of publicly-fundedservices for consumers with substance abuse concerns. These services are coordinated at the local levelthrough Local Management Entities (LMEs). LMEs are agencies of local government area authorities or countyprograms and are responsible for managing, coordinating, facilitating, and monitoring services and supportsin the catchment area they serve. LME responsibilities include offering consumers 24-hour a day, 7-day aweek, 365-days a year access to services and supports, developing and overseeing the provider network, andhandling consumer complaints and grievances. There are currently 24 LMEs that serve all 100 North Carolinacounties.

Measures of the delivery of services or treated prevalence are nationally accepted indicators of performance forthe service delivery system. The penetration or reach of services is an estimation for each Local ManagementEntity and within each LME the penetration varies across counties. The prevalence of substance abuse or theneed for services in the state is established annually for adolescents and adults separately utilizing the specificindicator, ‘dependence on or abuse of illicit drugs and alcohol in the past year by age group,’ from the NationalSurvey on Drug Use and Health for North Carolina.2 This proportion is applied uniformly to every LME in thestate to develop a LME specific age/disability prevalence estimate. Penetration or treated prevalence estimatesare calculated as a proportion of the number of claims submitted within a given timeframe to the number ofpeople within each LocalManagement Entity catchment area whowere estimated to need services. The numberof substance abuse consumers served within each LME catchment area is obtained through claim submissionsmade by each LME to the Division’s Integrated Payment and Reporting System (IPRS) and to the MedicaidProgram.

Maps 1 and 2 show the range of treated prevalence estimates by LME. Statewide, 3,689 adolescents (7% ofthose estimated to be in need of services) received state- or federal-funded services through the communityservice system from July 1, 2007 to June 30, 2008. The proportion of targeted adolescents who were servedvaried among LMEs from a low of 4% (Beacon Center andWake) to a high of 11% (Durham). The establishedSFY 2009 target for persons receiving adolescent substance abuse services is 9%; of the 23 LMEs with serviceclaim data, four LMEs (CenterPoint, Durham, ECBH, and Five County) met or exceeded this target. SandhillsandWestern Highlands came close to meeting the target at 8%. Similarly, 45,224 adults (8% of those estimatedto be in need of services) received federal- or state-funded substance abuse services through the communityservice system during the same timeframe. The proportion of adults who were served varied among LMEsfrom a low of 5% in Wake to a high of 11% in Johnston and Southeastern Regional. The established SFY 2009target for persons receiving adult substance abuse services is 10%.Of the 23 LMEs reporting service claims data,six LMEs (Albemarle, Five County, Johnston, Pathways, Southeastern Regional, and Smoky Mountain) met orexceeded the target.


Map 1.Treated Prevalance: AdultsWho Received Publicly-Funded Substance Abuse Services in North Carolinaby Local Management Entity, July 1, 2007 to June 30, 2008

Map 2.Treated Prevalance: AdolescentsWho Received Publicly-Funded Substance Abuse Services in North Carolinaby Local Management Entity, July 1, 2007 to June 30, 2008

The maps above show the range of treated prevalence among adults (Map 1) and adolescents (Map 2) receiving publicsubstance abuse services in the state of North Carolina. Statewide, 45,224 adults (8% of those in need of services) and3,689 adolescents 12 to 17 years of age (7% of those in need of services) received federal or state funded servicesthrough the state’s community service system from July 1, 2007 to June 30, 2008.North Carolina has designed its public system to serve those in highest need for ongoing care and limited access toprivately-funded services. Increasing delivery of services to these persons is a nationally accepted measure of systemperformance. This is measured by comparing the prevalence of the population that is estimated to have the condition ina given year, to the treated prevalence which is the percent of the population in need who receive the services for thatcondition within that year. The numbers served reflect adults, 18 and over, and adolescents, ages 12-17, who received anysubstance abuse services in the community system, paid through Medicaid and/or IPRS. Persons not included are thoseserved outside of the state Unit Cost Reimbursement (UCR) system or those paid by Medicare, Health Choice, TRICARE,county funds, other federal, state, or local funds, and private sources.Unless otherwise indicated, the LME name is the county name/s. The maps reflect LME configuration as of July 2008.

The data showcase the need for expansion of substance abuse services across the state to reach moreconsumers who may be in need. This pattern is not exclusive to North Carolina but is similar to many otherstates across the nation.3 As the report from the NCIOM Task Force on Substance Abuse Services puts it,“The prevention, diagnosis, and treatment of substance abuse are difficult for several reasons. A largepercentage of individuals with substance abuse problems do not seek treatment. In fact, national estimatessuggest that nearly 90% of people that abuse or are dependent on alcohol or illicit drugs never seek treatment.The few who do seek treatment often encounter problems accessing it due to service availability or cost. Thegeneral medical setting has not heretofore played a large role in the substance abuse treatment systemdespite the fact that if identified early and treated appropriately, substance use disorders can be successfullymanaged without further progression.”4

Contributed by:Spencer Clark, ACSW, assistant section chief, Community Policy Management Section, North Carolina Division of MHDDSAS

NiduMenon, PhD, epidemiologist, Community Policy Management Section, North Carolina Division of MHDDSAS

REFERENCES

1 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. State Estimates of Substance Usefrom the 2005-2006 National Surveys on Drug Use and Health. Rockville, MD: US Dept of Health and Human Services;2006.

2 Substance Abuse and Mental Health Services Administration. National Survey on Drug Use and Health. Research TriangleInstitute website. https://nsduhweb.rti.org/. Accessed January 21, 2009.

3 Goldsmith T. Report: many addicts not getting help. The News and Observer website.http://www.newsobserver.com/news/story/1366301.html. Accessed January 21, 2009.

4 North Carolina Institute of Medicine Task Force on Substance Abuse Services. Building a Recovery-Oriented System ofCare: A Report of the NCIOM Task Force on Substance Abuse Services.Morrisville, NC: North Carolina Institute of Medicine;2009. In press.


Spotlight on the Safety NetA Community Collaboration

Kimberly Alexander-Bratcher, MPH

Robeson County Bridges for Families ProgramTheRobesonCounty Bridges for Families Programbrings together an innovative groupof service agencies andpublic officials to meet an often unseen need. They are dedicated to supporting families whose children havebeen in, or are at risk for, placement outside of the home due to parental substance abuse issues. The programbegan in October of 2007 when the North Carolina Department of Health and Human Services was awardedoneof 53Regional PartnershipGrants from theUSDepartment ofHealth andHumanServicesAdministrationfor Children and Families. The goal of the Robeson County Bridges for Families Program is to “improve thesafety, permanency, andwell-being of childrenwhoare in out-of-homeplacement or are at risk for out-of-homeplacement as a result of their parent’s or caregiver’s methamphetamine or other substance abuse, as well asto improve the overall well-being and functional capacities of their families.” The primary clients served by theprogram are substance-involved families referred from the Robeson County Department of Social Services orFamily Treatment Court and/or a range of parenting support, mental health, and substance abuse treatmentservices.

The relationship between child maltreatment and substance abuse is often complicated by a host of personal,economic, environmental, and social factors. In order for substance abuse treatment to be effective, a programmust consider all of these issues. In addition to the necessary legal, substance abuse, and mental healthservices, theNorthCarolina Regional PartnershipGrant programprovides or arranges for gender-specific andfamily-focused wrap-around services that address related issues such as parenting skills, safety and domesticviolence, poverty, transportation, social support, and child care.

Since its inception, the program has added a Family Treatment Court; expanded treatment, includingenhanced residential care and transitional housing for families; and introduced four new evidence-basedsubstance abuse services: the Matrix Model Intensive Outpatient Program, Seeking Safety OutpatientGroups, Trauma Focused–Cognitive Behavioral Therapy, and the Strengthening Families Program. To buildcapacity in the region, 22 training events were arranged in the first year of the program. Trainings werefocused on substance abuse and the family, methamphetamine addiction, and evidence-based practicesfor treatment providers and the new Family Drug Court team. After the trainings, the Robeson CountyDepartment of Social Services dedicated staff resources to expand collaboration with community agenciesin order to help substance-involved families improve safety and permanency outcomes for their children.

A preliminary review of 2005-2006 data from social services case workers in Robeson County suggests thatparental substance abusewas a primary contributing factor in at least 29%of childwelfare caseswhere childabuse or neglect claims were substantiated or in which it was found that the family was in need of service.Substance abuse was also found to be a factor in 56% of the cases where children were placed in foster care.

In the start-up year of the program, 15 families and 25 children were served. The program estimates that overthe five years of the grant more than 200 substance-involved families engaged with the Robeson CountyDepartment of Social Services will benefit from the collaborative efforts of community partners working withthe Robeson County Bridges for Families Program and from the expanded array of services provided. Theprogram will seek to sustain itself by integrating efforts into existing systems and working with state leadersin the North Carolina Division of Social Services (DSS), the North Carolina Division of Mental Health,Developmental Disabilities, and Substance Abuse Services, and the North Carolina Administrative Office ofthe Courts.

Sherri L. Green, PhD, LCSW, research associate at the Cecil G. Sheps Center for Health Services Researchand research assistant professor for Maternal and Child Health at the University of North Carolina at Chapel Hill,

is the principal investigator for the program, and contributed to this article.

North Carolina is participating in a national evaluation effort of these types of programs with the findings tobe reported annually to Congress. Through use of data from process and outcome evaluations, the programwill serve as amodel for statewide strategic planning efforts to support best practices and systems of care thatwill enhance outcomes for North Carolina children and families affected by parental or caretaker substanceabuse.

The value of the program is highlighted by the participants. In interviews with community partners involvedwith the program, one partner stated, “We speak more freely, share information and ideas more readily, andsee each other as equal partners as opposed to peeking at each other from behind the safety of institutionalfences.” A partner from the guardian ad litem service said, “As a teammember working with the drug court,it has providedmewith a newway of thinking about substance abuse. I am nowmore patient in dealing withparents who are battling the disease of addiction. Drug court has given our families a new hope in regainingcustody of their children. Our families now see that they have a support system that includes the court andDSS, two entities that they previously viewed as obstacles in reuniting with their children.”

When discussing ways in which the program has influenced how agencies work with substance-involvedfamilies, a community partner stated, “The program represents a completely new way for us to deal withsubstance abuse. It is an uplifting program that focuses on proven strategies to assist people with theirrecovery [and] relates to participants in a way that does not lose sight of their worth as individual people.”Judge J. Stanley Carmical, who is the chief district court judge for Judicial District 16B and serves as thepresiding judge for the new therapeutic court, said, “I’m satisfied that even if you took themoney today, we’d[still] be 10 times better off than we were before the grant started.”

“I know that if I got a problem,” one participant stated, “I know that there is somebody there to help me. I getto go to mymeetings, go to the doctor, and get mymedicine. Drug court is good too ’cause they let me knowthat there is somebody there to help me make my life different. I just love my life today, because I know thatI am doing something different.”


Chief Medical DirectorAGAPE COMMUNITY HEALTH CLINIC

Washington, North CarolinaThe ideal candidate will be an experienced medical

provider with at least 5-10 years of experience in the deliveryofmedical services beyond residency. Sincewe are a federally-qualified community health center, prior experience in thissectorof health caredelivery is stronglydesired.Thecandidateshould be currently board certified in InternalMedicine, FamilyPractice, Pediatrics, or Med/Peds. The candidate should becomfortable and experienced in working with poor patientswith the ideal candidate having a strong desire to provideservices to the underserved residents of the community. Thecandidate should be comfortable working with mid-levelproviders for the delivery of health care services.

Metropolitan Community Health Services, Inc (MCHS) isseeking qualified candidates with a strong sense of missionanddesire to servewhowill also becomea community healthcare leader in the areas of quality of care.As such theDirectorwill convene the Quality Improvement multidisciplinaryconferences and establish the clinical standards of operationfor the clinic. Compensation ranges from $135,000 andhigher depending on experience, proven track record ingrowing health centers, and specialty. MCHS offers familymedical, sign-on bonus, relocation assistance, and incentivecompensation.

Housed in a newly constructed medical center, the facilityis state of the artwith on-site dental clinic, in-house pharmacy,radiology anddiagnostic imaging suites, community educationrooms, laboratory, and well-appointed telemedicine readyexamination rooms.

The Washington, North Carolina community has anexcellent school system and a peaceful quality of life. Thiswaterfront community has excellent housing options and isknown for its boating, equestrian, water sport, and golfingfacilities. Close to East Carolina University (19 miles) thereare plenty of opportunities to enjoy professional associationswith fellow physicians at the Brody School of Medicine andits teaching hospital.

Interested parties should send their CVs to Rev. Lynn E.Bolden, ChiefOperatingOfficer, at lbolden3 (at)mac.comorcall 252.945.2011.

Coming in theMarch/April2009 issueof the

North Carolina MedicalJournala look at:

PatientAdvocacy


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* Blue Cross and Blue Shield of North Carolina (BCBSNC) provides Member Health Partnerships (MHP), Blue Points and Online Healthy Living programs for member convenience and is not liable in any way for the goods or services received. Online Healthy Living programs are provided through MiaVita, Inc., a third-party vendor independent of BCBSNC. BCBSNC reserves the right to discontinue or change these programs at any time. These programs provide tools to aid members in improving their health; results are not guaranteed. Decisions regarding medical care should be made with the advice of a doctor. Some employers have elected not to make MHP or Blue Points programs available to their employees. Benefits available through MHP are subject to member’s current benefit plan and pre-existing waiting periods. Additionally, some of the MHP benefits may be different for members of BCBSNC’s high-deductible health plans. Members should check with their benefits administrator to determine their eligibility. An independent licensee of the Blue Cross and Blue Shield Association. U6226, 12/08oss and Blue Shield Association. U6226, 12/08of the Blue Cr

s high-deductible health plans. Members should check with their benefits administrator to deterent for members of BCBSNC’ferdiffferough MHP artheir employees. Benefits available thr

ding medical caregarguaranteed. Decisions reserves the right to discontinue or change these prBCBSNC r

and is not liable in any way for the goods or services rolina (BCBSNC) pross and Blue Shield of North CarBlue Cr*

tion. U6226, 12/08deductible health plans. Members should check with their benefits administrator to deter

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